Sunday, June 23, 2024

End of life choices explored

By permission of the New Zealand Medical Journal, we print below an edited excerpt of an article in their latest journal: Health professionals’ understanding and attitude towards the End of Life Choice Act 2019: A secondary analysis of Manatu- Hauora – Ministry of Health workforce surveys.

As of January 2023, Aotearoa New Zealand (NZ) is among the 25 jurisdictions/countries that have legalised assisted dying (AD). The NZ End of Life Choice (EOLC) Act 2019 (The Act) came into force in November 2021, following a 12-month implementation process. In NZ, AD practice encompasses euthanasia and physician-assisted dying allowing a person with a terminal illness to request medication to end their life if they meet strict criteria.

As a recent addition to the NZ health services, AD has implications for all health professionals. The Act stipulates that a health practitioner is entitled to conscientiously object to providing AD (Section 8(1) of the Act). Such practitioners are not legally required to disclose their conscientious objection however they do have a duty of care to respond when AD is raised.

This duty includes informing the patient of their right to seek a replacement practitioner and providing them with information about AD (Sections 9(2) and 10(2) of the Act).

This requirement highlights the necessity for all health professionals to be familiar with (1) the AD service and its care pathways; (2) the Act and its regulatory framework, eligibility criteria, and key safeguards; and (3) the three statutory roles established under the Act, including the Registrar (AD), the Support and Consultation for the End of Life in NZ Group, and the Review Committee.

The availability of a workforce to provide AD is partly contingent on health professionals’ competency and knowledge of the Act and AD services. International studies have highlighted the emotional and psychological burdens of providing AD on health professionals and the impact of these burdens on workforce availability if left unaddressed. Given that health professionals in NZ will increasingly encounter patients requesting AD, it is important to gain insight into their knowledge and attitudes towards the Act. This insight would help with the provision of AD service by ensuring support is available and minimising the burdens on the workforce.

The Ministry of Health (the Ministry) oversees the implementation of AD services in NZ and conducted two workforce surveys prior to the implementation of the Act. The purpose of these surveys was to gather baseline national workforce data in relation to the provision of AD. In this study, we analysed survey data to determine the sociodemographic factors associated with health professionals’ understanding of the Act, support for and willingness to provide AD.

Issues discussed

This is the first NZ study describing sociodemographic factors associated with health professionals’ understanding of the Act, support for and willingness to provide AD services in the year before the implementation of voluntary AD. In NZ, several studies were conducted before the AD legislation was passed to investigate public and health professional support for AD and sociodemographic factors that may influence this attitude.

Support for AD in the past 20 years has been relatively stable, averaging about 68 percent among the NZ public. The key findings of this study were: (1) older health professionals (age ≥55) had a better overall understanding of the Act than younger health professionals (age ≤35); (2) female health professionals were less likely to support AD and be willing to provide AD; (3) Asian and ‘other’ health professionals were less likely to support AD when compared with Pākehā/European professionals; (4) nurses were more likely to support and be willing to play a role in AD provision when compared with medical practitioners who can directly provide AD; and, (5) pharmacists were more likely to be willing to provide AD when compared with medical practitioners.

Age, understanding of the Act, and support for AD

The researchers found older health professionals had a better understanding of the Act. Older health professionals may have a higher AD literacy because they have been exposed to AD debates for longer since the first AD Bill was introduced in NZ in 1995. Over the twenty-six years between introducing the first bill and legislation coming into effect, these debates addressed topics such as what should be included in AD legislation, the decision-making process, and the level and legitimacy of the authorities given to those involved in the practice.

Similarly, health professionals working in hospices were found to have a better understanding of the Act, probably because they would have been exposed to the AD debate in their workplace due to the nature of their work caring for terminally ill people. In terms of age, a systematic review of physicians’ and nurses’ motivations to practice AD shows older practitioners are more inclined to provide AD.

Although, the NZMJ’s researchers did not find any association between age and support for or willingness to provide AD among health professionals in our study, their results are consistent with a previous NZ study which found age having a negligible association with acceptance of AD among the public,9 while mixed results about the correlation between age and support for AD were reported in other NZ studies.

Gender, support for and willingness to provide AD

The study found female health professionals were less likely to support or be willing to provide AD compared to their male counterparts. This finding is consistent with previous international reviews where male physicians and nurses are more likely to support AD.

By contrast, several studies of the NZ public have reported support for AD is similar in both genders. It appears that the relationship between gender and support for AD varies between the public and health professionals in NZ. Given that we could not identify any literature exploring this difference, future studies are needed to examine this potentially important finding.

Ethnicity and support for AD

Compared to the predominant European ethnicity, support for AD was significantly lower among Asian and “other” ethnicities. Previous studies of the NZ public have also found Asian and Pacific People were less supportive of AD. There has been no previous NZ research focused on Asian health professionals’ perspectives on AD, and international literature on this matter is scant.

The limited international literature on exploring culture-specific attitudes towards AD has concluded that some non-White ethnic groups, such as Asians, tend to show more humility and accept that not all parts of one’s life can be controlled or decided by humans.22 Of note, no Asian countries have yet legalised AD, which provides an additional indication of possible cultural factors in Asian attitudes towards AD.

Previous NZ studies on the general population have shown mixed results regarding support for AD amongst Māori, with some studies reporting very high support at or above 65%, or lower support than expected compared to other ethnicities.12 However, our study did not find any association between Māori health professionals and their support for AD or willingness to provide AD services. Further research into the perspective of Māori public and health professionals on AD and the Act is needed.

While mana motuhake (autonomy and self-determination) is important for Māori, this must be balanced against wairua (spiritual) and wider whānau responsibilities. Previous research has raised concerns about the potential harm to Māori, if AD is practiced without a full and meaningful understanding of the relationship between mātauranga Māori and AD.

Regardless, Māori health professionals have welcomed the opportunity to debate AD kaupapa (agenda), and those who participated in the survey have shown relatively high support for AD. There is a gap in knowledge regarding the link between understanding and willingness to be involved in AD from Māori health professionals’ perspective.

Professional background, support for and willingness to provide AD

Nurses in this study were more likely to support AD and be willing to provide AD when compared with medical practitioners. Existing studies suggest that there is a difference between nurses’ and physicians’ opinions about AD. Other NZ studies have also shown nurses are more likely to support AD than physicians, which is consistent with research elsewhere.

Nurses are often intimately involved in the care of patients seeking AD and are often the first point of contact in AD requests. Motivations to support AD have arisen from caring for people at the end of life prior to the introduction of the Act and witnessing suffering, despite best efforts in palliative care and sedation. However, the statutory and professional guidelines provide limited information on nurses’ scope of practice regarding AD.

Given the implications for registered nurses under the Act, NZ nurses’ regulatory authorities and professional organisations need to support government policy statements ensuring appropriate support is given to those requested AD regardless of the nurses’ stances on AD. In the Act’s statutory framework, only the role of attending nurse practitioners has been recognised as a practitioner who can legally prescribe and administer AD medication.

However, this must take place under the instruction of an attending medical practitioner (The Act, Section 4a). However, Nurse practitioners are not legally allowed to assess AD eligibility despite evidence suggesting they have the competency to do so.

Registered nurses’ (RN) roles and responsibilities are, on the other hand, unclear. RN responsibilities may include involvement in practical activities for AD preparation and administration, such as inserting intravenous lines and drawing up medications. The pressure felt by nurses to participate in AD to uphold their duty of care, even though conscientious objection is legally allowed, coupled with a lack of clarity around their obligations and protection, has raised concerns that need to be addressed.

Results from this study show that nurses and those identified as “other” health professionals were more likely to support AD. In contrast, nurses, pharmacists, and “other” health professionals were more willing to be involved in providing AD when compared to medical practitioners who have a direct role in relation to the AD provision.

To better understand the contribution to AD services from various health professionals, further evidence must be generated. For example, under the Act regulation, pharmacists are involved in AD services by dispensing lethal medication. Pharmacists’ willingness for a more active role in AD services could be facilitated by reforming the practice and medication protocols preparing for this role through education and resources provided for practice and continuing professional development.29 Application of these potential changes may, in turn, improve the provision of AD services.

The researchers note that this was the first national large-scale study specifically of health professionals’ views regarding the Act in NZ. It may provide the foundation for future research on attitudes and workforce data yet to be included in the NZ literature.

For detailed reference, please contact the New Zealand Medical Journal full document.

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