Preparing U of S health-care students for the new reality of end-of-life care

The passing of Bill C-14: Medical Assistance in Dying (MAID) on June 17, 2016 followed a landmark judgement by the Supreme Court of Canada and made it legal for patients who were suffering from an incurable medical ailment, and met a strict list of conditions, to choose the option to end their life. The new legislation had implications for not only patients and their families, but also for health-care providers who have to deal with the ethical dilemma and difficult decision of whether to choose to assist in helping a patient end their life.

“I think many physicians find it so different from the way we were trained, and that is the challenge,” said Dr. Susan Hayton, who graduated from medicine and law at the U of S and teaches about MAID in the College of Medicine. “This intervention was always illegal, and it was just not what we thought of ourselves as physicians, always trying to preserve life and extend life. But now I would say that much of the general public thinks this should be available and apparently most physicians do too, if you look at the statistics.”

According to a federal report released in June, there have been a total of 3,714 medically-assisted deaths in Canada since the legislation was adopted, including 39 in Saskatchewan during the most recent reporting period of July 1 to Dec. 31 of 2017.

While personal feelings about the issue vary widely among practitioners, faculty and students, the new legislation has required the university to help prepare the next generation of health-care professionals—doctors, nurses and pharmacists—for dealing with this new reality when they begin their careers.

“I think end-of-life care, in general, is more challenging for students and nurses to deal with because it is not an easy topic to approach,” said Janet Luimes, assistant professor and the acting director of the Nurse Practitioner Program in the College of Nursing. “But I think the more we talk about it and go through cases with students to equip them with the knowledge and skills in appropriately addressing end-of-life care, the more they become comfortable discussing it.”

The topic of medical assistance in dying is now covered in mandatory courses for all students—largely in ethics classes—in the Colleges of Medicine, Nursing, and Pharmacy and Nutrition. Once the legislation was officially adopted two years ago, all three colleges worked quickly to incorporate the subject into the curriculum.

“MAID was interesting legislation because I think it was ordered by the court system before the health system was really prepared to deal with it,” Luimes said. “In health care there has always been the idea of doing everything you can to save and cure the patient, so how do we deal with this? At first it was much more about understanding what the legislation means in practice and since then we have figured out where it fits best with our curriculum. So, we discuss it with end-of-life care, since it’s another aspect that needs to be addressed.”

Physicians and nurse practitioners can carry out assisted-dying procedures, while registered nurses can act as a witness. Meanwhile, pharmacists can be asked to supply the drugs used in the process, but do not take part in the actual procedure, which creates a unique ethical dilemma for that profession.

“(Pharmacists) have a very limited clinical role as they are not authorized under the Criminal Code to do much more that supply the drugs according to health system protocols,” said Ray Joubert, associate registrar in the Saskatchewan College of Pharmacy Professionals, the regulating body that oversees licencing for U of S pharmacy graduates to work in the province, as well as curriculum covering the topic.

“They must trust that others who are authorized properly educate and counsel the patient, obtain consent, obtain a second opinion, and administer the service. In other words, they must rely entirely on others who are authorized under the Criminal Code (mostly physicians) to confirm eligibility of the patient, consent for the care, and administration of the service,” said Joubert, who has covered the topic in ethics and law courses with pharmacy students.

For all three professions, no doctor, nurse or pharmacist can be forced to take part in any aspect of the assisted-dying process. However, if they do decline, they cannot abandon the patient. For a physician, this means “arranging timely access to another physician or resources, or offering the patient information and advice about all the medical options available,” according to the College of Physicians and Surgeons of Saskatchewan policy. Nurse practitioners have similar obligations.

“As a nurse, we have a code of ethics and the code of ethics states that we can’t abandon a patient,” Luimes noted. “So, if a patient requests medical assistance in dying and you don’t agree with it, you do have a duty to provide other aspects of nursing care to the patient while referring the patient to another provider to discuss medical assistance in dying.”

Both Hayton and Luimes said there has been a generational shift in acceptance by students, who are willing to at least discuss the topic even if they do not agree with the practice, for ethical, moral or religious reasons.

“Students pay attention to news and this was a huge news story and they want to know what the guidelines are for this and how this is going to affect them,” said Hayton, who was one of the first in the province to lecture about MAID once it became law, and presented on the topic and engaged in discussion about consent and the potential role of psychiatrists in physician-assisted dying, at the 2016 Saskatchewan Psychiatric Association annual conference. “And certainly not all, but many students that I teach, are maybe a bit more open to the idea than my generation was. So, I think that’s been a change.”

“I find my students are definitely open to discussing it,” Luimes added. “And I think it comes down to increased recognition and emphasis on the importance of patient-centred approaches in health care. So, while students may not agree with, they do respect a patient’s right to make an informed decision.”

Joubert said the majority of pharmacy students are also willing to tackle the topic in the classroom, although the discussions sometimes create more questions than answers.

“I find that they are very open to the subject from the perspective of intellectual curiosity, but become more reserved, or perhaps apprehensive, as they learn more about their potential role and the legal and ethical issues and challenges,” he said. “In other words, they appear as though they had not considered this role in selecting pharmacy as a career and exhibit some level of surprise as they learn more.”

Hayton said, in the end, it comes down to the concept of patient autonomy. Health-care professionals offer their diagnosis, treatment options and recommendations, but when it comes to medical assistance in dying, it’s the patients who have the right to make the final decision, once all the requirements are met.

“You give the patient your best medical advice, but ultimately, they have the final say about what to do with their body,” she said. “And the whole idea of physician-assisted dying plays into that because maybe they don’t want to do what is suggested because it will be too much suffering and maybe they want to choose the time and method of their death. So, it’s all about patient autonomy and quality of life. And I think we can all respect that.”