Abstract
Background
New Zealand’s End of Life Choice Act 2019 was enacted in 2021, allowing terminally ill people experiencing unbearable suffering to request assisted dying if they are expected to die within six months. Healthcare professionals not directly involved in assisted dying provision may have unique perspectives on implementation, yet this remains under-explored.
Methods
This qualitative study was conducted between June and November 2022. We used purposive and snowball sampling to recruit potential participants through various sources, including the Ministry of Health’s assisted dying training and communication email list. A multidisciplinary research team developed a semi-structured interview guide. The individual interviews were recorded, transcribed, and thematically analysed to identify core themes.
Results
Ten healthcare professionals with palliative and primary care backgrounds participated. Five main themes were generated: diverse views on assisted dying; views on the End of Life Choice Act; the interface between palliative care and assisted dying services; education on palliative care and assisted dying; and self-care coping and support. Participants expressed varied attitudes and ethical concerns, with most emphasising the need for reforms in eligibility criteria and improved public understanding. These healthcare professionals provided valuable insights into the broader impact of assisted dying on the healthcare system and the complexities of integrating it with palliative care.
Conclusions
Integration between palliative care and assisted dying services is crucial for delivering patient-centred care and addressing stigma surrounding end-of-life choices in New Zealand. Adapting international policies around eligibility criteria and safeguards can help streamline the process.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12904-025-01838-8.
Keywords: Assisted dying, Ethics, Palliative care, Legal frameworks, Support systems
Background
The implementation of assisted dying legislation creates significant changes in healthcare environments, affecting not only providers directly involved in the process but also those working in adjacent roles [1]. New Zealand’s End of Life Choice Act 2019 was enacted in 2021, marking a significant development in the discourse surrounding end-of-life care in New Zealand and sparking debates amongst healthcare professionals, policymakers, and the general public [2]. Some argue that a legal right to die grants individuals autonomy and control over their own lives [3], whereas others express concerns about the potential for abuse and the moral implications of assisted dying.
International research from jurisdictions with established assisted dying frameworks reveals complex experiences amongst healthcare professionals. Studies following Medical Assistance in Dying (MAiD) implementation in Canada demonstrated that healthcare professionals experienced emotions ranging from professional fulfilment to moral distress, with nurses being the most consulted professionals during assessment processes [4, 5]. In the Netherlands, research spanning over two decades showed ongoing challenges, including administrative burden and moral boundary concerns [6], while an Australian study revealed polarised attitudes influenced by professionals’ beliefs, emotions, and education [7]. Research in Switzerland demonstrated the tension between assisted suicide and suicide prevention within hospital settings, highlighting the complex ethical navigation required of healthcare professionals [8]. Similar patterns of moral complexity were revealed amongst healthcare providers in Oregon and Washington, with physicians reporting both professional satisfaction and ethical concerns about their involvement [9, 10]. Finally, Belgian research highlighted the importance of interdisciplinary team support and the challenges of maintaining therapeutic relationships when patients request euthanasia [11, 12].
Previous literature has identified critical gaps in understanding the experiences of healthcare professionals who are not directly involved in assisted dying. Brooks et al. (2019) called for investigation into the experiences of diverse healthcare providers beyond physicians and nurses [13], while Ward et al. (2018) emphasised insufficient research on interprofessional roles and dynamics in assisted dying provision [14]. A systematic review demonstrated that healthcare professionals experienced moral distress and emotional burden when they participated in assisted dying; however, they also expressed a sense of fulfilment in providing relief to patients who are suffering [4]. These findings emphasise the need for support mechanisms to enhance patient care and reduce burnout amongst healthcare professionals [15].
New Zealand’s End of Life Choice Act 2019 presents a unique legal framework with distinctive features requiring jurisdiction-specific research (Box 1) [16]. The introduction of assisted dying in New Zealand has led to challenging practice changes for healthcare professionals working in palliative and end-of-life care [17]. Two New Zealand studies explored healthcare professionals’ initial experiences following the enactment of the End of Life Choice Act 2019. The first study highlighted the emotional and ethical dilemmas faced by healthcare providers, emphasising the need for improved training, support systems, and communication strategies for discussing end-of-life options and managing family dynamics [17]. The second study set the research agenda for assisted dying in New Zealand and called for research on the long-term psychological impacts on assisted dying providers and best practices for patient-provider communication [18].
Box 1.
Eligibility criteria of New Zealand’s End of Life Choice Act 2019
| Adapted from the End of Life Choice Act 2019 [17] |
| A person is eligible for assisted dying if they are: |
| 1. aged 18 years or older |
| 2. a New Zealand citizen or permanent resident |
| 3. suffering from a terminal illness likely to end their life within six months |
| 4. in an advanced state of irreversible decline in physical capability |
| 5. experiencing unbearable suffering that cannot be relieved in a manner the person considers tolerable; and |
| 6. competent to make an informed decision about assisted dying. |
New Zealand’s bicultural (Māori and non-Māori) health system, publicly funded healthcare structure, and early implementation phase provide opportunities to capture real-time experiences of healthcare professionals who are not directly involved in assisted dying provision, a perspective that is under-represented in international literature [17, 18]. Understanding these indirect experiences is essential for successful implementation, as these professionals provide ongoing care to patients considering assisted dying, collaborate with assisted dying providers, and contribute to institutional culture surrounding end-of-life care options. Therefore, the aim of this study was to investigate the experiences of healthcare professionals indirectly involved in assisted dying during the first year of legalised assisted dying in New Zealand. The findings could help guide policy decisions, improve training, and create support systems for healthcare professionals who are not directly involved but are nonetheless affected by assisted dying.
Methods
Research design
This study employed a qualitative research design to explore the experiences of healthcare professionals indirectly involved in assisted dying in New Zealand. The study was conducted between June and November 2022, within the first 12 months of legalised assisted dying in New Zealand. A qualitative approach was chosen to capture detailed accounts of healthcare professionals’ experiences. This method provided a deeper understanding of their perspectives, emotions, and ethical considerations regarding assisted dying.
Sampling and recruitment
We used purposive and snowball sampling to recruit participants through multiple channels. Email invitations were sent via the Ministry of Health’s assisted dying training and communication emailing list, as well as emailing lists from the Australian and New Zealand Society of Palliative Medicine and the New Zealand Assisted Dying Research Network. In addition, invitations were posted on the New Zealand Women in Medicine Facebook Group.
Potential participants were asked to contact the research team if they were interested in participating in this research. To be eligible, participants needed to be health professionals who had been indirectly involved in assisted dying, meaning they had treated at least one patient who had requested assisted dying but had not directly assessed eligibility or administered the procedure. To acknowledge their time and contributions, participants received an NZD 100 gift voucher.
Data collection
A multidisciplinary research team with expertise in psychology, sociology, gerontology, psychiatry, nursing, ethics, and Kaupapa Māori research created a semi-structured interview guide (Appendix). Te Ārai, a palliative care research group, Kāhui Kaumātua, provided cultural advice in the conduct of this study. The interview guide covered various topics, progressing from basic to reflective enquiries, including eligibility criteria, assessment resources, the personal and professional impact of assisted dying, and self-care. The participants were interviewed either via Zoom or in person. The interviews were audio-recorded with permission and transcribed verbatim by a professional transcriber under a confidentiality agreement.
Data analysis
The participants were invited to review their own transcripts for accuracy before analysis. The transcripts were analysed via the six-phase process described by Braun and Clarke: (i) familiarising with data; (ii) generating codes; (iii) combining codes into themes; (iv) reviewing themes; (v) determining the significance of themes; and (vi) reporting findings [19].
The reporting of this study has been guided by the Standards for Reporting Qualitative Research (SRQR). NVivo (Release 1.5.2; QSR International) was used for data organisation, coding, and theme generation. The first author conducted the analysis in partnership with the second and last authors. Initial codes based on the interview guide were developed collaboratively. An inductive approach was employed to extract analytic codes from interviews coded line by line. This process resulted in the generation of ten top-level codes and fifty-six child codes. An iterative process was undertaken to revisit and adjust codes and themes until consensus was achieved, resulting in the identification of primary themes. The outcome themes were iteratively reviewed to ensure a comprehensive analysis.
Results
Participant characteristics
A total of ten healthcare professionals participated in this study: five palliative care specialists (Participants 1, 2, 3, 4, and 5), one participant dually trained in palliative care and general practice (Participant 6), one palliative care nurse (Participant 7), two general practitioners (Participants 8 and 9), and one primary care nurse specialist (Participant 10). Most participants were New Zealand European (n = 8), one was Chinese, and one was Indian. Half of the participants were aged between 50 and 59 years; three were aged between 40 and 49 years; one was aged between 30 and 39 years; and one was aged 60 years or older. These healthcare professionals practised in various settings: public hospitals (n = 3), general practices (n = 2), hospice care (n = 4), and the community (n = 5). The duration of their clinical experience ranged from five to over 30 years.
All study participants had indirect experience with assisted dying through their work, as one participant explained: “As a palliative care clinician, my patient selection is already such that they’ve been referred to us for a reason. The reason they often ask for end-of-life care is uncontrolled symptoms or issues, whether psychologically or physically” (Participant 1, Palliative Care Specialist). While they were not directly involved in assisted dying assessments or procedures, they encountered patients who, due to uncontrolled symptoms or psychological distress, considered it as an option. Their roles involved managing end-of-life care, which sometimes led to discussions around assisted dying, especially when symptom management was insufficient. Many expressed that these discussions were part of their broader efforts to alleviate suffering, even though they did not actively participate in the assisted death procedure itself.
Thematic analysis
The average duration of the interviews was 90 min (range: 70 to 110 min). Five primary themes were generated, each supported by participants’ experiences and perspectives.
Theme 1: diverse views on assisted dying
Participants’ views were diverse, ranging from neutral or indifferent to being against assisted dying. However, participants described the importance of neutrality as an effort to uphold objectivity and fulfil professional obligations.
“You know I’m not pro or anti; I’m just trying to look at it from an outside perspective” (Participant 2, Palliative Care Specialist).
Our participants emphasised their commitment to impartiality when they responded to enquiries about assisted dying. One participant highlighted patients who sought assisted dying because their symptoms were not well controlled.
“As a palliative care clinician, my patient selection is already such that they’ve been referred to us for a reason. The reason they often ask for end-of-life care is uncontrolled symptoms or issues, whether psychologically or physically. Therefore, I tend to focus on that” (Participant 1, Palliative Care Specialist).
Ethically, participants faced dilemmas regarding assisted dying. Some expressed strong reluctance to be directly involved in administering life-ending treatments, feeling that it crossed a professional and moral boundary.
The language used by participants to describe their ethical concerns reflects the intensity of moral conflict experienced, with some employing stark terminology that depicts the profound nature of these professional and personal boundaries.
“I don’t think I’d be willing to be the one to kill the patient. It’s a truly big deal killing somebody” (Participant 6, Palliative Care Specialist and General Practitioner).
“I don’t think I signed up to be a doctor knowing that I would have to kill people. Therefore, I do not think I could be the one who actually killed somebody. That would be a step too far” (Participant 5, Palliative Care Specialist).
Theme 2: views on the end of life choice act 2019
Some participants felt frustrated because of the legal constraints that hinder open discussions with patients about assisted dying. While the participants acknowledged the existing legal framework, they expressed a desire for honest and transparent conversations on the topic.
“I think it would be nice to be able to present it (assisted dying) as an option in a non-judgemental way, but at the moment, we can’t” (Participant 7, Palliative Care Nurse).
The participants expressed concerns about the six-month life expectancy criterion, finding prognostic certainty challenging to determine.
“The prognostic criteria are very difficult. Six months is a very difficult timeframe to have any degree of certainty” (Participant 4, Palliative Care Specialist).
The participants also raised concerns about capacity assessment. Many participants advocated for more stringent regulations, particularly in clinical situations such as delirium. They emphasised ensuring that patients who opt for assisted death are in a sound state of mind and stressed the need for thorough capacity assessment.
“Therefore, it does worry me that the competency hasn’t been assessed thoroughly. I would have thought by now they would have needed to have used the psychiatrist just statistically” (Participant 8, General Practitioner).
Theme 3: interface between palliative care and assisted dying services
The participants stressed the need for collaboration between palliative care and assisted dying services. Concerns were raised regarding potential divisions, prompting the call for unity to avoid fragmentation. The participants highlighted a prevalent misconception amongst patients, who often perceived palliative care and assisted dying as mutually exclusive.
“I advocate for better collaboration between palliative care teams and assisted dying teams. Without working in tandem, it risks becoming a hopeless division. I have witnessed this divide, and it urgently needs addressing” (Participant 2, Palliative Care Specialist).
To bridge this gap, participants suggested that assisted dying practitioners should gain a deeper understanding of palliative medicine to facilitate holistic care beyond assisted dying.
“It would be immensely beneficial if assisted dying practitioners spent time in a hospice or with a palliative medicine service. Understanding what palliative medicine provides is key to offering holistic care beyond facilitating assisted dying” (Participant 4, Palliative Care Specialist).
Examining the broader context of palliative care and assisted dying services reveals the significant influence of media discourse on professional experiences. Palliative care specialists in our study reported a prevalence of negative narratives and personal attacks from assisted dying proponents through social media platforms. This negative discourse, distinct from but interconnected with clinical interface challenges, added additional stress to palliative care practitioners.
“The extra, the added stress and burden of dealing with people who are requesting assisted dying, and then also the nastiness from proponents of assisted dying on social media, has been truly hard for people to put up with” (Participant 5, Palliative Care Specialist).
Theme 4: education on palliative care and assisted dying
Our participants provided insights into the role of education, training, and guidelines for both healthcare professionals and patients. Public understanding of palliative care and assisted dying is crucial. The participants suggested the need for patient education at the individual and societal levels to dispel misconceptions regarding palliative care and assisted dying.
“Even before the debates about it, the public does not actually know what palliative care is or what it does. Education for the public would be truly helpful” (Participant 2, Palliative Care Specialist).
Our participants acknowledged the importance of healthcare professionals being educated on assisted dying. The importance of educational initiatives in preparing palliative care clinicians for the complexities associated with the End of Life Choice Act was also emphasised. They recognised the fear and ignorance surrounding assisted dying and advocated for first-hand experience.
“We have been educating our team well before the Act came into force. You need to be prepared for it” (Participant 2, Palliative Care Specialist).
Finally, the participants stressed that healthcare professionals and patients would benefit from access to clear information on the assisted dying process, including details about contacting relevant authorities and understanding procedural requirements. The need for printed information to aid individuals in the process was highlighted.
Theme 5: Self-Care, coping, and support
Our participants highlighted the complexities and emotional toll associated with their roles, emphasising the need for tailored support systems and coping strategies in palliative care, particularly in the context of the additional layer of assisted dying legislation. The palliative care practitioners in our study shared insights into the inherent challenges of their profession, notably citing palliative care and oncology as specialties that are prone to burnout.
“Palliative care and oncology are the two largest burnout specialties. They involve dealing with people, especially young patients, facing distressing conditions” (Participant 2, Palliative Care Specialist).
They identified self-care practices as an essential component in overcoming the difficulties posed by assisted dying implementation. The participants also highlighted the importance of regular professional supervision, often with health psychologists, in alleviating work-related stress. These sessions provided a platform for discussing challenging decisions and interactions.
Discussion
This study offers one of the first in-depth explorations of healthcare professionals’ indirect experiences with assisted dying in New Zealand during the initial phase of the End of Life Choice Act 2019. Although participants were not involved in assessing eligibility or administering assisted dying, they played essential roles in managing care for patients who considered or ultimately chose this option. Their perspectives shed light on the broader ethical, emotional, and systemic challenges emerging at the intersection of palliative care and legalised assisted dying.
The diversity of participants’ views on assisted dying reflects the moral pluralism within New Zealand’s healthcare workforce. Some clinicians viewed assisted dying as a legitimate expression of patient autonomy and relief from suffering, while others expressed deep ethical unease. These tensions mirror national survey data showing that support for assisted dying varies by profession, gender, and ethnicity [20, 21] and reflect a broader international trend in which clinicians simultaneously express compassion for suffering patients and concern over the moral implications of life-ending interventions [15]. The strong emotional language employed by some participants, including terms like “killing”, reflects genuine moral struggles that merit analytical attention. Such language reveals the intensity of internal conflict many experience and signals a need for values-based dialogue and institutional structures that allow ethical diversity to be respected within clinical teams.
Participants expressed significant frustration with specific aspects of the End of Life Choice Act 2019, particularly the six-month prognosis requirement and the legal prohibition on initiating assisted dying discussions. These were perceived as barriers to open, honest communication and to timely, informed decision-making. International comparisons are instructive: Canadian legislation permits clinicians to raise assisted dying under certain conditions, while also allowing eligibility to be based on intolerable suffering rather than a fixed prognosis [22, 23]. These differences suggest that New Zealand’s more restrictive framework may inadvertently place additional stress on clinicians, limit patient autonomy, and create avoidable ethical dilemmas.
One of the most important findings of this study is the perceived divide between palliative care and assisted dying services. Many participants described tensions between these domains, including negative public perceptions, misunderstandings amongst patients, and a lack of systemic integration. This echoes earlier concerns that legalising assisted dying without embedding it into palliative care frameworks risks fragmenting care and undermining trust [17]. Participants advocated for better collaboration between palliative and assisted dying practitioners, including shared training and opportunities for assisted dying providers to gain firsthand experience with palliative principles. Integrated models, such as those being developed in Canada, may help New Zealand avoid entrenching a siloed approach and instead support coordinated, person-centred care [24].
Education and training were consistently identified as gaps. Despite playing key roles in end-of-life care, many participants felt unprepared to engage in conversations about assisted dying or respond confidently to patient enquiries. This aligns with international findings that stress the need for comprehensive education that spans legal literacy, communication skills, ethical reflection, and emotional resilience [4, 25]. Participants also called for improved public education to counter widespread misconceptions about both assisted dying and palliative care—a point that reinforces earlier findings on the need for system-wide communication strategies [18].
The emotional burden on clinicians was significant. Even in the absence of direct involvement, participants described increased stress, moral conflict, and burnout risk. These findings reinforce research from Canada and elsewhere showing that assisted dying-related work can have profound psychological impacts, especially in already demanding specialties such as palliative care and oncology [4, 15]. Access to regular professional supervision, peer support, and structured reflection opportunities emerged as essential mechanisms for coping with this complex emotional labour. Importantly, some participants also spoke of the fulfilment they experienced in alleviating suffering, echoing the duality seen in prior international literature [4].
Taken together, these findings signify the systemic impact of assisted dying in New Zealand and highlight the need for responsive, values-informed clinical and policy frameworks. As New Zealand’s assisted dying landscape evolves, lessons from this study can help guide ethically robust implementation that centres on patient dignity while safeguarding practitioner wellbeing [26, 27].
Strengths and limitations
The main strength of this study is its contribution to an underexplored area: the indirect experiences of healthcare professionals with assisted dying in New Zealand. It captures the perspectives of a diverse group of practitioners, including nurses, general practitioners, and palliative care physicians, all of whom play crucial roles in end-of-life care despite not being directly involved in the assessment or administration of assisted dying. This diversity enhances the richness and relevance of the findings and provides valuable insights for informing future policy and practice [28].
Our recruitment process encountered challenges due to the sensitive nature of the topic and a limited pool of eligible participants. While the sample size is small, this is consistent with qualitative research methodology, which prioritises depth and nuance over generalisability [29]. Given the qualitative nature and small sample size of this study, these findings should be interpreted with appropriate consideration of transferability rather than generalisability. The experiences described by these New Zealand healthcare professionals may resonate with those in similar healthcare systems implementing assisted dying legislation. Factors such as cultural context, healthcare system structure, and specific legislative frameworks may influence the applicability of these findings to other settings [30]. The purposive sampling strategy ensured that participants were well-positioned to provide informed and meaningful perspectives. The findings suggest potential patterns that may warrant further investigation with larger, more diverse samples. Future research could benefit from broader recruitment strategies, such as partnering with professional organisations or using digital outreach platforms, to increase sample size and participant diversity.
The predominance of New Zealand European participants in this study represents a limitation in capturing the full diversity of healthcare perspectives in New Zealand. Limited representation of Māori and Pacific healthcare professionals highlights an important area for future research, particularly given the significance of cultural frameworks in end-of-life care decision-making. Future research would also benefit from incorporating tikanga Māori perspectives and indigenous health frameworks, particularly given New Zealand’s bicultural commitments and the importance of culturally responsive end-of-life care approaches that honour diverse worldviews and practices around death and dying.
Regarding reflexivity, it is important to acknowledge that several research team members practise within palliative care and psychiatric specialties. Their professional backgrounds and clinical experiences likely influenced both data collection approaches and analytical interpretations. While this insider knowledge provided valuable context for understanding participant perspectives, it may have shaped how questions were framed and how responses were interpreted. This positioning was managed through collaborative analysis involving researchers from different disciplinary backgrounds and ongoing reflective discussions throughout the analytical process.
Key recommendations for consideration
Based on the experiences shared by these ten participants, several areas may warrant further exploration and consideration by policymakers and healthcare organisations:
Integration and collaboration
The participants’ experiences suggest potential value in greater integration between palliative care and assisted dying services to prevent fragmentation and promote holistic, person-centred care.
Education and training
The findings indicate possible benefits from comprehensive educational programmes that might equip healthcare professionals with skills and ethical frameworks for managing assisted dying-related situations with competence and compassion.
Support systems
These insights suggest the potential importance of organisational leadership and clinical governance in supporting healthcare professionals during implementation transitions, including fostering environments where emotional resilience, reflective practice, and open ethical dialogue may be institutionalised.
Policy development
The participant perspectives suggest areas where eligibility frameworks might be examined, drawing from international models while maintaining appropriate safeguards.
These recommendations reflect the preliminary nature of findings from a small qualitative sample and would benefit from validation through larger-scale research and broader stakeholder consultation.
Conclusions
This study suggests that healthcare professionals not directly involved in assisted dying provision experienced complex emotional, ethical, and professional challenges during the implementation of assisted dying legislation. These professionals, primarily from palliative care, general practice, and nursing, appeared to occupy critical frontline roles in supporting patients at the end of life and navigated a complex new terrain marked by moral ambiguity, regulatory limitations, and shifting patient expectations. While this study represents preliminary insights from ten healthcare professionals, these perspectives suggest potential areas for attention in assisted dying implementation that warrant broader research and stakeholder consultation.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
The authors would like to thank for the practitioners for participating in this study.
Author contributions
All authors contributed to study design. AD conducted the qualitative interview. WA led the qualitative analysis, supervised by GC and AD. WA drafted the manuscript and other authors critiqued and revised the manuscript. All authors approved the final version for submission.
Funding
Auckland Medical Research Foundation.
Data availability
Availability of data and materials: The qualitative data generated and/or analysed during the current study are not publicly available due to the consent the respondent gave but are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
All procedures performed in this study involving human participants were in accordance with the ethical standards of the University of Auckland Human Participants Ethics Committee (Reference: UAHPEC24335). All participants provided written informed consent.
Consent for publication
Not applicable; this manuscript does not include any individual person’s data.
Competing interests
GC was a member of the New Zealand Ministry of Health’s Support and Consultation for End of Life in New Zealand (SCENZ) Group from 2021 to 2023.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Availability of data and materials: The qualitative data generated and/or analysed during the current study are not publicly available due to the consent the respondent gave but are available from the corresponding author on reasonable request.