New Report Guides Oncology Nurses in Medical Aid in Dying Practices

States are increasingly passing legislation allowing patients to request medical assistance in their death, commonly referred to as medical aid in dying (MAID). Seven states currently have this legislation, and more than 70% of patients who request MAID have a cancer diagnosis. Health care professionals rarely receive training on responding to requests for MAID. The Clinical Journal of Oncology Nursing recently published an article by Thalia DeWolf, RN, BSN, PHN, CHPN, to educate oncology nurses.

Definition of MAID

The authors define MAID as the process by which physicians provide a medication or prescription to patients who explicitly request it, with the intent that the patient would use the medication or prescription to end their life. Most patients who request this approach express concerns about loss of dignity and quality of life, and most receive palliative and hospice care. The authors distinguish that MAID is neither euthanasia (which is illegal) nor patient suicidality (which has not been shown to correlate directly with requests for MAID).

Eligibility

Most states use the same criteria for MAID. A patient must:

1. Be at least 18 years old,
2. Reside in a state where MAID is legal,
3. Have a prognosis of 6 months or less,
4. Make 2 oral requests for MAID, including a waiting period between the first and second,
5. Provide a written request, signed by the patient, in the presence of 2 witnesses,
6. Have 2 physicians who agree on the patient’s diagnosis, prognosis, and decision-making capacity.

Some states recommend a psychological evaluation of the patient if concerns about judgment are suspected. The primary physician writing the MAID order must also review alternatives, including hospice, pain control, and comfort care. Patients are always allowed to change their minds.

Medications

The most commonly prescribed MAID pharmaceutical combination includes benzodiazepines, barbiturates, morphine sulfate, antidepressants, and cardiotoxins. Specifically, the most common medications are diazepam, digitalis, morphine, amitriptyline, and phenobarbital. This medication is compounded into a powder form which must be ingested via the gastrointestinal system either orally or through a gastral or rectal tube.

Nursing Considerations

The authors list several considerations for nurses caring for patients considering MAID. (1) Nurses should avoid judgmental statements or actions if a patient requests MAID. Since patients often feel comfortable discussing private concerns with nurses, it is paramount that nurses support their patients’ choices and self-determination. (2) Nurses should be aware of their state’s laws and regulations as well as their institution’s policies regarding MAID. Even if they are not the ones providing the medications, a nurse’s role as an advocate is still critical and includes providing patient education, referrals, and continued care. (3) Nurses should follow the steps outlined by the Hospice and Palliative Nurses Association when a patient asks about MAID, including:

1. Clarify their request,
2. Assess the patient to understand what elicited the request,
3. Evaluate and refer the patient for any unmanaged symptoms,
4. Develop short- and long-term plans with the patient to discuss their needs,
5. Collaborate with the interprofessional team to provide comprehensive care for the patient’s quality of life.

Nurses have the right to conscientiously object to being involved in the MAID process, though they should express this to their employers to identify alternative providers.

The eligibility, process, and conversations surrounding MAID are complex and evolving, involving multiple layers of professional rules, considerations, and dynamics. Building on this introductory article, the authors offered further suggested readings, including the American Clinicians Academy on Medical Aid in Dying and Death with Dignity.

Reference

Medical aid in dying: an overview of care and considerations for patients with cancer