YRNA MAiD Statement

 

 

YRNA STATEMENT REGARDING

MEDICAL ASSISTANCE IN DYING

 

 

Table of Contents

      Background

      How Does MAiD Differ from Palliative Care?

      What Eligibility Requirements and Safeguards Did the Canadian Government Enact?

      What Is the Role of the Nurse Practitioner?

      What Can Nurses Do with Respect to MAiD?

               What Should I Do if I Am Asked to Aid in MAiD as a Member of the Health Care Team?

               What Should I Do if a Person Asks Me to Administer the Medication that Causes a Person’s Death?

               What Should I Do if Those Persons Requesting MAiD Ask Me to Act as an Independent Witness to a Signature on a Request for MAiD?

      What Actions Put Me at Risk?

      What Can I Do if MAiD Conflicts with My Personal Beliefs or Values?

      Conclusion

      Resources

      Reference List

 

Background

 

Medical Assistance in Dying (MAiD) is defined in the Criminal Code as:

(a) the administering by a medical practitioner or Nurse Practitioner of a substance to a person, at their request, that causes their death; or

(b) the prescribing or providing by a medical practitioner or Nurse Practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their own death. (aide médicale à mourir)

 

As nurses “are the health-care professionals who people talk to and question most often….Nurses often hear from people who ask that they be allowed to die and who may be seeking advice about how they can end their suffering. Nurses therefore have a unique perspective and bring an important contribution to providing end-of-life care that includes medical assistance in dying” (Canadian Nurses Association, 2015). A nurse in the Yukon, can aid a Nurse Practitioner (NP) or medical practitioner to provide MAiD, but they must be aware of and adhere to the Criminal Code eligibility requirements and safeguards and consider their personal values andprofessional obligations, which include knowing what to do if asked to participate in MAiD, how to uphold standards of practice and what actions may put them at risk.

 

In the case of Carter v. Canada, the Supreme Court of Canada (SCC) considered whether the criminal prohibition on a person assisting another in committing suicide violates the Charter rights of competent adults who are suffering intolerably from grievous and irremediable medical conditions (as defined further in the Criminal Code 241.2 (2)) and seek assistance in dying. The SCC unanimously determined an absolute prohibition on assisting a person to commit suicide does violate the Charter rights of those individuals and is unconstitutional. Accordingly, the SCC created an exemption to the relevant Criminal Code provisions on suicide to allow for physician-assisted death [now referred to as MAiD] if certain criteria are met by those persons.

 

On June 17, 2016, the federal government’s Bill C-14, ‘An Act to amend the Criminal Code and to make related amendments to other Acts’ (medical assistance in dying) received royal assent and became law in Canada. The Act’s provisions amend the Criminal Code and establish the parameters in which MAiD can be legally administered. The Criminal Code states that “no person is a party to culpable homicide if they do anything for the purpose of aiding a medical practitioner or Nurse Practitioner to provide a person with medical assistance in dying in accordance with section 241.2” (CC 271 (2)). (Criminal Code s.227(2)).

 

How Does MAiD Differ from Palliative Care?

 

The Criminal Code provisions on MAiD do not affect a nurse’s important role in providing quality end-of-life care, also known as palliative care. Palliative care focuses on comfort and quality of life for people of all ages affected by life-threatening illness.

Medical assistance in dying provides those persons whose natural death is reasonably foreseeable and who are experiencing intolerable suffering due to a grievous and irremediable medical condition the option to request to end their life with the assistance of a medical practitioner or Nurse Practitioner. MAiD is only available to eligible persons. The eligibility criteria and safeguards for patients are listed in the Criminal Code. The Government of Yukon, in conjunction with the Yukon Hospital Corporation, is determining processes for how MAiD is delivered.

 

What Eligibility Requirements and Safeguards Did the Canadian Government Enact?

 

Nurses are health care professionals who may aid a practitioner in MAiD and are protected from criminal penalty in doing so as long as they strictly adhere to the MAiD Criminal Code provisions, use reasonable knowledge, care and skill, and comply with any applicable territorial laws, rules or standards on MAiD. Therefore, nurses involved with MAiD will have to be aware of these prior to participating. As always, RNs and NPs are encouraged to contact a CNPS legal advisor (1-800-267-3390) to discuss the legal risks associated with participating.

 

Although nurses are not expected to assess eligibility for MAiD, they must raise concerns if they believe those persons requesting MAiD do not meet the criteria, which are:

 

Eligibility for Medical Assistance in Dying

 

(Criminal Code 241.2(1)) A person may receive medical assistance in dying only if they meet all of the following criteria:

(a) they are eligible—or, but for any applicable minimum period of residence or waiting period, would be eligible—for health services funded by a government in Canada;

(b) they are at least 18 years of age and capable of making decisions with respect to their health;

(c) they have a grievous and irremediable medical condition;

(d) they have made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure; and

(e) they give informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care.

 

(Criminal Code 241.2(2)) A person has a grievous and irremediable medical condition only if they meet all of the following criteria:

(a) they have a serious and incurable illness, disease or disability;

(b) they are in an advanced state of irreversible decline in capability;

(c) that illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and

(d) their 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.

 

Safeguards for Medical Assistance in Dying

 

(Criminal Code 241.2(3)) Before a medical practitioner or Nurse Practitioner provides a person with medical assistance in dying, the medical practitioner or Nurse Practitioner must:

(a) be of the opinion that the person meets all of the criteria set out in subsection (1);

(b) ensure that the person’s request for medical assistance in dying was:

(i) made in writing and signed and dated by the person or by another person under subsection (4), and

(ii) signed and dated after the person was informed by a medical practitioner or Nurse Practitioner that the person has a grievous and irremediable medical condition;

(c) be satisfied that the request was signed and dated by the person—or by another person under subsection (4)—before two independent witnesses who then also signed and dated the request;

(d) ensure that the person has been informed that they may, at any time and in any manner, withdraw their request;

(e) ensure that another medical practitioner or Nurse Practitioner has provided a written opinion confirming that the person meets all of the criteria set out in subsection (1);

(f) be satisfied that they and the other medical practitioner or Nurse Practitioner referred to in paragraph (e) are independent;

(g) ensure that there are at least 10 clear days between the day on which the request was signed by or on behalf of the person and the day on which the medical assistance in dying is provided or—if they and the other medical practitioner or Nurse Practitioner referred to in paragraph (e) are both of the opinion that the person’s death, or the loss of their capacity to provide informed consent, is imminent—any shorter period that the first medical practitioner or Nurse Practitioner considers appropriate in the circumstances;

(h) immediately before providing the medical assistance in dying, give the person an opportunity to withdraw their request and ensure that the person gives express consent to receive medical assistance in dying; and

(i) if the person has difficulty communicating, take all necessary measures to provide a reliable means by which the person may understand the information that is provided to them and communicate their decision.

 

What Is the Role of the Nurse Practitioner?

 

NPs are recognized in the Criminal Code as having a role in medical assistance in dying.

As a Nurse Practitioner in accordance with the Registered Nurses Profession Regulation (2012) Part 1 (1), the scope of practice of a Nurse Practitioner under subsection 13.1(2) of the Act is subject to the conditions that the practice must (a) be within the Nurse Practitioner’s educational preparation and individual competence and (b) utilize appropriate consultation and referral mechanisms to meet patient needs.

YRNA recommends that Yukon NPs can determine the eligibility of the person requesting medical assistance in dying based on the eligibility and safeguard criteria established in the Criminal Code of Canada and the RNPA Regulation (2012), Part 1. 

In accordance with the Criminal Code and the RNPA Regulation, Part 1 (2012), Yukon NPs can provide MAiD by administering the medical assistance in dying substances to a person, at that person’s request, that causes that person’s death. Yukon NPs cannot prescribe drugs associated with medical assistance in dying in accordance with the RNPA Regulation (2012), Part 2, until such time as there are regulatory changes made to the schedule on drugs a Nurse Practitioner can prescribe.  Nurse Practitioners can act as a second practitioner in assessing a patient’s eligibility for MAiD.

In accordance with the Criminal Code and the RNPA Regulation (2012), Part 1, NPs can provide the medical assistance in dying substances to a person, at that person’s request, so that that person may self-administer the substance and, in doing so, cause their own death. The Yukon Medical Council has established a Standard of Practice in the delivery of MAiD that Yukon NPs are encouraged to review (http://yukonmedicalcouncil.ca/pdfs/MAID.pdf).

In accordance with the Criminal Code and the RNPA Regulation (2012), Part 1, NPs can aid in the provision of MAiD by a medical practitioner or another Nurse Practitioner.

In addition to meeting these requirements, NPs are expected to work with their employer(s) to ensure they meet all relevant agency policies and standards related to the provision of medical assistance in dying.

We encourage Yukon NPs to contact the YRNA office when they are determining appropriate educational preparation for medical assistance in dying.

 

What Can Nurses Do with Respect to MAiD?

 

If acting in compliance with the law and in good faith, nurses—along with other health care professionals—are protected under the law to:

“provide information to a person on the lawful provision of medical assistance in dying” (Criminal Code, s.241(5.1));

“do anything for the purpose of aiding a medical practitioner or Nurse Practitioner to provide a person with medical assistance in dying in compliance with 241.2” (Criminal Code, s.241(3));

[aid] that other person to self-administer a substance that has been prescribed for that other person as part of the provision of medical assistance in dying” (Criminal Code, s.241(5)).

At this time, CNPS advises against aspects of self-administration.

 

What Should I Do if I Am Asked to Aid in MAiD as a Member of the Health Care Team?

 

This means nurses must:

      provide objective information about MAiD and answer the person’s questions (Standard 2);

      refer to a medical practitioner, the person’s providing practitioner and other appropriate members of the health care team for further consultation and follow up;

      document the experience (the fact that the person has raised the issue of MAiD and relevant parts of my exchange with them) in the person’s record in a timely and accurate fashion (Standard 2.8), following employer guidelines and, where applicable, including identification of people present in the room and name of the provider who administers MAiD;

Note: Tampering with documents related to MAiD is a criminal offence.

      work collaboratively with the health care team (Standard 3.5) and employer to determine how nursing services can best be delivered to meet needs while remaining within the law;

      communicate clearly so that issues are resolved effectively and the person’s care is not impacted;

      reassure the person that they have contacted the health care team about requests (Standard 3.2);

      continue to treat the person’s pain and suffering irrespective of the assisted death conversation (Standard 3);

      maintain the privacy and confidentiality of those persons involved in MAiD, including respecting the person’s wishes about communicating with family members (Standard 4.3); and

      provide information using reasonable knowledge, care and skill in accordance with applicable territorial laws, rules or standards (Standard 1.2).

 

What Should I Do if a Person Asks Me to Administer the Medication that Causes a Persons Death?

 

Nurses are not authorized to administer the medication that causes a person’s death under any circumstances (even if requested by the providing practitioner/NP and/or those persons requesting MAiD); however, nurses may aid in the administration of the medication at the direction of the providing medical practitioner/NP, including inserting intravenous lines used to administer the medication and being present during the administration of the medication.

 

What Should I Do if Those Persons Requesting MAiD Ask Me to Act as an Independent Witness to a Signature on a Request for MAiD?

 

Nurses may act as an independent witness as long as: (1) they understand that the document is a formal request for MAiD, (2) they do not know or believe that they are a beneficiary under the will of the person or a recipient in any other way of a financial or material benefit resulting from the person’s death, (3) they are not an owner or operator of any health care facility in which the person resides and (4) they are not directly involved in providing personal or health care services to the person.

 

What Actions Put Me at Risk?

 

Nurses should understand important distinctions between definitions of “counsel.” The Criminal Code defines “counsel” as inciting or encouraging; however nurses consider ‘counseling’ to mean information sharing aimed at developing awareness of health options. CNPS cautions that nurses, for their own protection, “must be mindful not to encourage, suggest, counsel or incite a person to seek MAiD” (Canadian Nurses Association, August, 2016).

 

If a nurse is approached to be involved with MAiD, it is their responsibility to understand the legal requirements under the Criminal Code of Canada and any territorial legislation. A nurse who knowingly fails to comply with legal requirements may be convicted of a criminal offense and/or financial penalties.

 

Please consult with your employer, the YRNA and CNPS if you have any questions about your involvement in MAiD.

 

What Can I Do if MAiD Conflicts with my Personal Beliefs or Values?

 

A nurse may decline to participate in any aspect of MAiD; however, they should refrain from directly expressing “moral objection or judgements about the beliefs, lifestyle, identity or characteristics of the person requesting MAiD” (Canadian Nurses Association, August 2016) and they must:

         be answerable for their professional actions, decision and conduct (Standard 1.5);

         take measures to maintain fitness to practice such that the person’s safety is not compromised (Standard 1.6);

         inform their employer (or person requesting MAiD if self-employed) promptly of their objection;

         continue to provide safe quality care until alternative arrangements are made to meet the person’s needs and wishes in respect to MAiD;

         provide nursing services in a professional, non-judgmental, non-discriminatory way;

         take care not to “impose their own views and values onto others nor use their position to influence, judge or discriminate against others whose values are different from their own” (Canadian Nurses Association, August, 2016).

         explore clinical options for client care; and

         raise any discrepancies with process.

The Canadian Nurses Association Code of Ethics (www.cna-aiic.ca) contains information on ethical considerations in addressing expectations that are in conflict with one’s conscience.

 

Conclusion

 

Whether or not a nurse is involved in MAiD, there is an obligation to provide safe, competent, professional and ethical care to the person and his or her family at all times. A compassionate response to a person’s comment about wanting to die may include spiritual care, palliative care (or other symptom management), counselling services or other services, depending on the reasons for suffering. The Yukon Registered Nurses Association is committed to supporting nurses by communicating the eligibility requirements and safeguards that the federal government has enacted to ensure Canadians have access to MAiD while remaining mindful of the spectrum of nurses’ personal convictions.

YRNA will continue to work with the Government of Yukon as it aims to establish the best means of serving Yukoners and employers as they create policies to determine how MAiD is being delivered.

Remember, YRNA members can seek legal support from the Canadian Nurses Protective Society (CNPS), which is specifically tailored to meet professional liability needs: www.cnps.ca.

For additional background information, please refer to the CNPS articles available at www.cnps.ca: "A ‘Right to Life’ is not a ‘Duty to Live,’" “Medical Assistance in Dying: What Every Nurse Should Know?” and “Physician-Assisted Death: What Does this Mean for Nurses?”

 

Resources

 

1.    CNA’s Code of Ethics (https://www.cna-aiic.ca/en/on-the-issues/best-nursing/nursing-ethics)

2.    YRNA’s Standards of Practice (http://yrna.ca/wp-content/uploads/Standards2013.pdf).

 

Reference List

 

1.    Criminal Code, R.S.C. 1985. Accessed June and July 2016. Retrieved from http://laws-lois.justice.gc.ca/eng/acts/c-46/FullText.html

2.    Bill C-14: An Act to Amend the Criminal Code and to Make Related Amendments to Other Acts (Medical Assistance in Dying) (2016) 42nd Parliament, 1st Session. Retrieved from the Parliament of Canada website: http://www.parl.gc.ca/HousePublications/Publication.aspx?Language=e&Mode=1&Parl=42&Ses=1&DocId=8255777

3.    Code of Ethics for Registered Nurses (June 2008). Canadian Nurses Association. Ottawa, ON. Retrieved July 27, 2016, from https://www.cna-aiic.ca/~/media/cna/files/en/codeofethics.pdf

4.        Yukon Registered Nurses Association Standards of Practice (Effective January 2013). Retrieved July 27, 2016, from http://yrna.ca/wp-content/uploads/Standards2013.pdf)

5.       Canadian Nurses Association. (2015). Canadian hospice palliative care association & Canadian hospice palliative care nurses group.

6.       Canadian Nurses Association. (August, 2016). National nursing framework on medical assistance in dying (consultation draft).

7.      Registered Nurses Profession Act. (2012). Retrieved from the Yukon Government website: http://www.gov.yk.ca/legislation/regs/oic2012_198.pdf

8.    Yukon Medical Council. (2016). Yukon Medical Council- Standard of Practice Medical Assistance in Dying. Retrieved from: http://yukonmedicalcouncil.ca/pdfs/MAID.pdf

 

CNPS Articles:

1.    A “Right to Life" Is Not a "Duty To Live” (February 13, 2015)

2.    Medical Assistance in Dying: What Every Nurse Should Know (July 7, 2016)

3.    Physician-Assisted Death: What Does This Mean for Nurses? (February 17, 2016)

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Last Revision: October 7, 2016

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