Medical assistance in dying: A reflection tool for pharmacists

Scenario

A pharmacist recently participated in a medical assistance in dying (MAiD) provision for the first time. In this instance, their involvement primarily centred on the dispensing of medications. Despite their lack of familiarity with the patient and their family, the pharmacist has struggled to process a gamut of emotions. The pharmacist does not feel comfortable discussing their experience with others and instead expresses a wish to unpack their thoughts and feelings so that they are better able to understand their emotions. What resources are available to support this pharmacist?

Introduction

When medical assistance in dying (MAiD) was made available across Canada in 2016, ¹ little was known about pharmacists’ roles and experiences in practice. ² Since then, pharmacists working in a variety of practice settings have gained experience with MAiD as the number of provisions has increased each year. ³ Up to the end of 2022, there were 13,241 MAiD provisions in Canada, taking place in private residences (39.5%), hospitals (30.5%) and palliative care facilities (20.8%). ³

Internationally, pharmacists have been involved in some aspects of assisted dying since the late 1990s. ² The focus and extent of pharmacists’ involvement in assisted dying depend on current legislation in each jurisdiction. Pharmacists’ responsibilities in MAiD may encompass medication dispensing, review of medications with the physician or nurse practitioner, postprovision collection of medications and supplies and documentation of legal requirements.^4,5 Although pharmacists’ roles have been largely focused on the physical processes for medication handling, there is an emerging recognition that pharmacists’ involvement in MAiD is patient-centred.^6,7

There is growing evidence characterizing the experiences of health care professionals involved with MAiD as emotional. ⁸ An individual’s professional values and level of engagement influence the emotional impact of MAiD. ⁹ Some of the stressors described by health care professionals include a feeling of isolation, a culture of secrecy, lack of support, few opportunities to talk about experiences, challenging relationships with colleagues who object and witnessing the grief of others.^10,11 Pharmacy students have reported concerns regarding the dispensing aspect of MAiD as well as issues they may encounter when practising in direct patient care. ⁸ A study of hospital pharmacists’ experiences with MAiD in Alberta highlighted the emotional aspect of the experience and that each pharmacist experienced MAiD practice in a unique way. ¹²

The need to support health care professionals to process their experiences with MAiD has been recognized. Research with physicians emphasized the importance of reflecting on experiences and talking about them with colleagues. ⁸ Physicians who shared their experiences with colleagues coped with the process better than did physicians who could not access similar support. ¹³ Confiding in like-minded colleagues strengthened physician relationships and supported learning from each other. ¹³ For nurses, their manager’s support was key to establishing an environment conducive to open dialogue about experiences. ¹¹ Research with pharmacists reported that they valued opportunities to discuss their experiences with others involved in MAiD.^7,11,12 However, conversations in clinical settings may not provide adequate support, as they have been described as stigmatized and treated with secrecy.^11,12 There is a need to support conversation and reflection on pharmacists’ perspectives, challenges and experiences with MAiD.

The purpose of this article is to introduce a reflection tool developed to support pharmacists caring for patients seeking MAiD.

Development of the tool

The tool was developed to support individuals who are engaged in assisted dying practice to

• • reflect on their experiences, roles and emotions,

• • connect with others to share experiences, and

• • identify ways to enhance future MAiD practice.

The development process encompassed 3 integrated phases. In the initial phase, collaborative efforts between the authors and a psychologist led to the formulation of a reflection process grounded in the principles of reflective practice. ¹⁴ This process drew insights from recent research concerning pharmacists’ engagement in assisted dying practice and MAiD.^12,15 Subsequently, the tool underwent evaluation in the second phase of development using interviews (n = 11) with experienced hospital pharmacists who had provided care for patients seeking MAiD (n = 7). This approach yielded valuable feedback, specifically regarding the tool’s applicability and overall usability. The third and final phase centred on a comprehensive review of the tool’s content and design by a psychologist and experts in the field of assisted dying practice (n = 2).

The tool

The tool is designed as a workbook offering designated space to record responses and notes (Appendix 1 in Supplemental Materials section). The tool is available in 2 PDF formats: as a printable workbook for writing by hand or as a fillable form for digital input. The workbook may be accessed and downloaded at https://cshp-scph.ca/medical-assistance-dying-maid-reflective-tool-pharmacists.

The tool is organized into 4 distinct sections: experience, role, emotions and future practice (Figure 1). Each of these sections contains a set of guiding questions to aid individuals in reviewing their engagement with MAiD. Additionally, each section integrates suggestions for collaborative reflection, fostering the opportunity to connect with peers and collectively share experiences.

Figure 1.

MAiD reflection tool: experience, role, emotions and future practice

The “role” section of this tool incorporates a framework comprising 8 dimensions, previously designed to explore the roles assumed by pharmacists involved in assisted dying practice (Figure 2). ¹⁵ Pharmacists who evaluated this tool found the framework to be a valuable guide for contemplating their individual roles within the realm of MAiD. The reflection process of this activity follows a methodical approach: each dimension is defined (displayed on the left side) and accompanied by a quantifiable scale (displayed on the right side). This scale empowers and facilitates the assessment of roles and experiences across the spectrum of each dimension. As a fundamental aspect of this reflective exercise, individuals using the tool are encouraged to examine the rationale underpinning the positioning of their role along the continuum of the given dimension.

Figure 2.

Framework for exploring roles in MAiD

How to use the tool

To gain full value from this tool, users should do the following:

• Take time to reflect on a specific experience with MAiD practice.

• Consider using the tool soon after each MAiD experience. However, the tool can also be used long after an experience has occurred.

• Work through all sections. However, there are many ways to use this tool, such as focusing on a specific section or starting at any section.

• Write responses to the guiding questions, thinking about answers to the questions, talking with others or using any other method of reflection or combination that works.

• Use the tool individually or in conversation with others, such as a trusted colleague, manager, therapist or psychologist.

Limitations of the tool

The limitations of the MAiD reflection tool may be attributed to its development based on research conducted with pharmacists planning to implement assisted dying practice ¹⁵ and pharmacists practising in Alberta hospitals. ¹² Additionally, although the tool provides a series of guiding questions to facilitate the reflection on experiences, these questions do not cover all possible aspects of caring for patients seeking MAiD. Pharmacists may find it necessary to expand their reflection in specific areas, depending on their own unique experiences and practice settings. Assisted dying is a sensitive and confidential topic; using a tool may inspire individuals to record personal experiences and emotions that they may be uncomfortable sharing due to privacy concerns. Ensuring confidentiality while using the tool is required. Although this tool has been evaluated by pharmacists with MAiD experience, regular updates to the tool are essential to incorporate feedback from pharmacists who have used it. To access the most current version of the tool, pharmacists are encouraged to visit the CSHP website at https://cshp-scph.ca/medical-assistance-dying-maid-reflective-tool-pharmacists.

Conclusion

This tool was developed to support pharmacists in reflecting on their experiences, roles and emotions in their care of patients seeking MAiD. Additionally, the tool acts as a guide for connecting with colleagues, facilitating the exchange of experiences and identifying strategies to enhance future involvement in MAiD. This tool has the potential to support not only pharmacists but also other pharmacy staff, pharmacy students and pharmacists who are engaged in MAiD across diverse professional settings.