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“It’s a big difference between having an opinion on something and actively doing it:” physician and nurse practitioner non-participation in medical assistance in dying



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Medical assistance in dying (MAID) became legal in 2016 with the Royal Assent of Bill C-14. There are numerous considerations and several challenges when developing safe and sustainable MAID programs in Canada. In the face of these challenges, competent and compassionate healthcare practitioners (HCPs) who are willing to participate in the formal MAID processes of patient assessment and MAID provision are essential. This thesis included a scoping review which identified, analyzed, and synthesized the factors that influenced HCPs' non-participation in ethically complex, legally available healthcare and a qualitative exploratory study that illuminated the factors that influenced physicians and nurse practitioners (NPs) when deciding not to participate in the formal MAID processes of determining a patient’s eligibility and providing MAID. Five themed factors that influenced HCPs' non-participation in ethically complex, legally available care were identified in the scoping review. While conscientious objection (CO) frequently dominated the discourse regarding HCPs’ non-participation care, it was clear that multiple factors beyond ethical, religious, or core moral belief also influenced HCPs’ non-participation. Thirty-five non-participating HCPs were interviewed over five months in Saskatchewan, Canada in the qualitative exploratory project. Considering Social Contract Theory and Ruggerio’s approach to moral dilemmas and decision-making, the endogenous and exogenous factors that influenced their non-participation threshold were identified. Endogenously HCPs’ were influenced by their (1) previous personal and professional experiences, (2) comfort with death, (3) conceptualization of duty, (4) preferred EOL care approaches, (5) faith or spirituality beliefs, (6) self-accountability, (7) consideration of emotional labour, and (8) concern regarding future emotional impact. Exogenously, HCPs’ non-participation was influenced by (1) the healthcare system they work within, (2) the communities where they live, (3) their current practice context, (4) how their participation choices were visible to others, (5) the risks of participation to themselves and others, (6) time factors, (7) the impact of participation on the patient’s family, and (8) patient relationship and contextual factors. Non-participation in formal MAID processes occurred along a spectrum and was influenced by these complex, interwoven, and diverse endogenous and exogenous factors. This dissertation's key findings are that non-participation in ethically complex, legally available care (including MAID) includes both conscientious objection to care and non-participation in care and culminated in the development of the Model of Non-Participation in Formal MAID Processes. Practice considerations to support patients and HCPs in the evolving social contract of end-of-life care are offered to support safe and satisfying workplaces and patients' access to care.



Medical Assistance in Dying, conscience, physician, nurse practitioner, non-participation



Doctor of Philosophy (Ph.D.)




Health Sciences


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