Institutional non-participation in medical assistance in dying: Why non-participation policies persist within Saskatchewan hospitals and their impact on patients and providers
Notice bibliographique
Résumé
Medical assistance in dying (MAiD) was thrust into the policy spotlight a decade ago when the Supreme Court of Canada unanimously ruled that prohibiting assisted dying infringed upon the constitutional rights to life, liberty, and security of the person for consenting patients with grievous, irremediable medical conditions who experience intolerable suffering (Carter v. Canada, 2015). Since then, Canadian policymakers have been tasked with balancing the rights of MAiD-seeking patients with the interests of potentially vulnerable persons and those who oppose MAiD. Given the profound impact of MAiD, empirical evidence is vital to inform these policies. One policy that has garnered considerable controversy is institutional non-participation, which occurs when an entire institution opts out of MAiD provision. I conducted a patient-orientated, theory-driven case study to examine the existence of institutional non-participation in MAiD within Saskatchewan (SK) hospitals and to explore the impacts of these polices. SK is considered a critical case as it is one of the most rural provinces in Canada with a long history of Christian involvement in hospital care. Data were collected through semi-structured interviews with 24 participants, including policymakers, healthcare providers, and family members of MAiD patients, and review of relevant policy documents. Analysis was both deductive based on theoretical propositions of the guiding frameworks and inductive to identify novel themes and advance knowledge in this area. Results are presented using the three-paper-model with each addressing a distinct research question. First, historical institutionalism (Campbell, 2004) was used to examine how MAiD non-participation policies emerged and evolved within SK hospitals (Chapter 2). Faith-based conscientious objections appear to underpin all hospital non-participation in SK. These policies are maintained by powerful actors within the Catholic church and government, the dominance of traditional paradigms, and the existence of drifts in practice that emerged prior to MAiD legalization. However, non-participation policies have softened over time due to policy diffusion, patient advocacy groups, and an alternate policy paradigm rooted in patient autonomy. Second, the impacts of institutional non-participation in MAiD were explored from the perspective of the patient-and-family-centered care model (Brown et al., 2022) and Levesque’s (2012) conceptual framework for access to health (Chapter 3). Positive impacts included safe havens, enhanced trust, and opportunity for improved locations or final visits. However, negative impacts were more salient and affected MAiD-seeking patients (physical pain, emotional, relational, disruptions, delays, and constrained choice), family members (vicarious trauma, complicated grief, time consumption at end of life, costs, and stigma), care providers (relational, emotional, moral injury, limited autonomy, increased workload, fear of misstep, and targets of abuse), and healthcare systems (increased complexity, resource strain, and MAiD process). SK’s unique model of centralized MAiD delivery appeared to be intimately related to both the impact and evolution of institutional non-participation policy in SK. Chapter 4 first applies the multiple streams model (Kingdon, 1984) to the adoption of centralized delivery; it then explores the benefits and challenges of this delivery model. Benefits of centralized delivery included improved quality of care (continuity, coordination, efficiency, consistency, accessibility, and patient-centeredness), enhanced supports for providers, and system-level benefits. Challenges include urban concentration, shortage of providers, and perceived lack of resources. This study provides a deeper understanding of the complex policy space in which non-participation policies persist, which is necessary to inform future policy development regarding institutional non-participation in controversial healthcare practices, including MAiD. Keywords: medical assistance in dying, institutional non-participation, conscientious objection
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Prédiction machine sur la base complète
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Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,012 | 0,017 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,001 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,001 | 0,004 |
| Études des sciences et des technologies | 0,021 | 0,028 |
| Communication savante | 0,011 | 0,004 |
| Science ouverte | 0,003 | 0,010 |
| Intégrité de la recherche | 0,002 | 0,005 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,003 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».