The euthanasia law from the perspective of healthcare professionals in Spain

Abstract

Background

In 2021, Spain passed Organic Law 3/2021, which regulates euthanasia and represents an extension of rights to make decisions in the context of health care. According to the Law, the state must guarantee access to Medical Assistance in Dying (MAiD) through health services. Therefore, the involvement of health professionals is crucial. The aim of this work is to analyse the perspectives of health professionals on the provision of MAiD. Particular attention is paid to the social impact of the Law, the conceptual problems it raises, and the distribution of rights and responsibilities of professionals and patients, as well as the procedural aspects included in the regulation, the experiences of professionals regarding MAiD, and the implementation differences observed among regions.

Methods

It was an exploratory qualitative research applying a thematic analysis through semi-structured interviews with physicians and nurses from primary care, hospital care, and palliative care, recruited from three Autonomous Communities in Spain (Madrid, Catalonia, and Andalusia) between March and May 2023.

Results

A total of 25 interviews were conducted with medical and nursing professionals, 17 women and 8 men. The information collected was organised according to these discursive axes: social impact of the Law; terminological and conceptual problems; rights and responsibilities of professionals and patients; procedure (time limits, role of professionals); experiences of professionals regarding MAiD; and differences in implementation among the regions of the study. For this analysis, the participants’ positions on the provision of MAiD were considered.

Conclusions

The professionals interviewed generally express a positive assessment of the legal safeguards of MAiD Law in Spain. However, challenges remain in its implementation, such as perceived legal ambiguities, assessment of suffering, and balancing autonomy. Structural inequalities and limited support may affect access and provider well-being. Strengthening professional training, teamwork, and institutional resources, as well as a relational approach, is essential. The findings offer practice-based guidance for policy and clinical care and highlight the need for further research on real-world impacts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-025-01320-3.

Background

The approval of Organic Law 3/2021 on Euthanasia in Spain (LORE, by its Spanish acronym) [1] has recognised the right to request and receive the provision of Medical Assistance in Dying (MAiD) in the case of a serious, chronic, and incapacitating condition or a serious and incurable disease that causes unbearable suffering (arts. 1, 4, and 5 LORE). These scenarios include both terminally ill people and non-terminally ill people.

The Law provides for euthanasia (active and direct intervention by a healthcare professional that intentionally leads to death) and medically assisted suicide (professional action that provides the patient with the necessary means to self-administer death). Here, for the sake of brevity, we will use MAiD to refer to both euthanasia and medically assisted suicide, although euthanasia has been the most common practice (316 versus 18 in 2023, according to the latest official data published) [2].

Personal and documental conditions are required to access the procedure (Table 1). Additionally, there are three mandatory prior verification filters: the responsible physician, the consultant physician, and the Guarantee and Evaluation Commission. This multidisciplinary commission is created at regional level as a body with pre- and post-verification functions. It is one of the main differences with other countries with approved regulations, where the commissions only have functions after MAiD has been provided, not before. The Law also regulates the right of the health professionals directly involved (physician and nurse) to exercise conscientious objection.

Table 1.

Organic Law regulating Euthanasia in Spain: Purpose, conditions, and procedure

Purpose	To regulate the right to request and receive Medical Aid in Dying (MAiD), as well as the duties of healthcare professionals and institutions
Place of application	Public or private healthcare facilities, or at home
Clinical scenarios	Euthanasia and medically assisted suicide
Personal requirements	− Legal age − Spanish nationality or legal residence for at least 12 months − Capable and conscious at the time of the request − Suffering from a serious and incurable illness, or a debilitating chronic condition causing unbearable physical or psychological suffering
Documentation requirements	− Request must be made in writing by the individual concerned (caregivers or third parties are excluded) − 2 voluntary written requests, at least 15 days apart, if the patient can postpone the date − A statement outlining the reasons for the request − Informed consent prior to the provision − In cases of incapacity, an advance directive may be used
Procedure	Phase 1: Pre-provision Verification (40 days). Three levels of review must be completed: 1. Responsible physician: verifies all requirements, provides written information, and collects informed consent. If the request is denied, the patient may appeal to the Commission of Guarantee and Evaluation (CGE) 2. Consultant physician: reviews the clinical history and may interview the applicant. Issues a report to the responsible physician 3. Commission of Guarantee and Evaluation (CGE): 2 members review the case and issue a report. If unfavorable, the patient may file an administrative appeal Phase 2: Provision of MAiD − Euthanasia: administered by the responsible physician/healthcare team until the patient’s death − Medically Assisted Suicide: the responsible physician prescribes the substance for self-administration, while observing and supporting the patient until death Phase 3: Post-provision Verification Responsible physician must submit documents to the CGE within 5 days. The CGE verifies compliance and issues a report within 2 months

MAiD implementation has been received with relief by those who have waited a long time for access [3], but at the same time, it has posed challenges for healthcare professionals. In this regard, the Law has challenged a certain understanding of the traditional aims of medicine, grounded in its commitment to the respect for and preservation of human life—a perspective from which MAiD may be regarded as alien to both professional duties and the Ethical and Deontological Codes of the medical profession [4, 5].

In addition, in a context where healthcare services were still closed or saturated and their staff exhausted due to the COVID-19 pandemic, different expectations were generated, accompanied by confusion [6], especially in those Autonomous Communities where the initial administrative support was lower [7, 8].

Since the entry into force of LORE on June 2021 and until December 2023, 1,515 MAiD requests have been attended, of which 697 have been carried out [2]. More than half of them were in Catalonia (339), Madrid (133), and Andalusia (70), which are the three Autonomous Communities1 where this research was conducted, with significant differences among them. These differences are striking and cannot be explained simply by socio-cultural differences among regions [7]. The different speeds of the regional reactions after the approval of LORE are well known [8]. While Catalonia had the necessary regional regulation to apply the Law in June 2021 [9], Madrid and Andalusia were the last Communities to approve their respective norms [10, 11], and not without obstacles in their articulation [12–14].

In Spain, MAiD is a right that entails obligations for healthcare professionals and public administrations [1]. Therefore, it is relevant to know the vicissitudes of the procedural aspects and the experiences of professionals with this new provision. Empirical studies conducted on MAiD from the perspective of healthcare professionals in the Spanish context are still scarce [15–18] and have mainly focused on Catalonia [6, 17] and Andalusia [17], sometimes limited to a single professional group [15, 16]. This work aims to expand knowledge about the practice in these and other parts of the territory, analysing the assessment made by physicians and nurses with different positions on MAiD in Andalusia, Catalonia, and Madrid, and comparing them with each other.

The study has been developed along the following thematic axes: the views of professionals on the social impact of the Law; what issues they consider problematic in the legal text; how they evaluate the distribution of rights and obligations for professionals and patients; what their assessment of the MAiD procedure established in LORE (time limits, role, and experiences of professionals); and what regional differences they have identified in the implementation of MAiD.

Methods

Aim, design, and setting of the study

The aim of this article is to analyse the perspectives of healthcare professionals (physicians and nurses) in Andalusia, Catalonia, and Madrid on Organic Law 3/2021, which regulates euthanasia in Spain. The inclusion of healthcare professionals from these Autonomous Communities was intentional, based on population size, case incidence, and practice refusal index, in order to capture a wide range of experiences and perspectives regarding the implementation of the Law. These regions represent different regulatory, institutional, and cultural contexts that may influence the practical application of the Law and the experiences of the professionals. This diversity enhances the study’s ability to identify barriers, facilitators, and potential inequalities in access to MAiD across regions.

An exploratory qualitative design based on a thematic approach was used to explore in depth participants’ interpretations of the Law and their experiences [19]. Semi-structured interviews were used to allow participants the flexibility to express their views and experiences in their own words, and to facilitate rich, contextualised data collection. The interview script (see Supplementary File 1) was developed following the goal of this study and based on previous knowledge on the topic [20]. It was piloted with seven key informants, all healthcare professionals trained in bioethics, with extensive experience in end-of-life practices, knowledge of MAiD implementation, and members of healthcare ethics committees or Guarantee and Evaluation Commissions. These interviews provided contextual information to approach the study objective and helped to improve the final script. The present article is based on the results corresponding to Sects. 2 to 4 of the script (“Interviewee profile,” “Ethical conflicts at the end-of-life,” and “Evaluation of the Spanish Organic Law regulating Euthanasia”). The authors translated the original Spanish verbatims, aiming to preserve their meaning and ensure comprehensibility for English-speaking readers.

Characteristics of participants and inclusion criteria

The fieldwork was carried out between March and May 2023 with 25 healthcare professionals (physicians and nurses) from Andalusia (9), Catalonia (8), and Madrid (8) (Table 2). Although the number of MAiD cases is higher in Catalonia, a similar number of interviews was conducted across regions due to discourse saturation. After a certain point, additional interviews did not provide new insights or themes, indicating that data saturation had been reached. This ensured that the sample was sufficient for qualitative analysis, regardless of regional differences in the volume of cases.

Table 2.

Characteristics of participants

Participants’ characteristics		Number (N = 25)		percentage
Autonomous Community	Catalonia Andalusia Madrid		8 8 9	32% 32% 36%
Gender	Female Male		17 8	68% 32%
Experience	> 10 years 10–20 years 20 y 30 years < de 30 years		8 6 6 5	32% 24% 24% 20%
Profession	Medicine Nursing		17 8	68% 32%
Areas	Public Private		22 3	88% 12%
Health care setting	Primary Care Hospital - Palliatives - Intensive - Internal - Neurology		13 5 1 3 3	52% 20% 4% 12% 12%

None of the contacted persons refused to participate and they were only interviewed once. The main inclusion criterion was that they were healthcare professionals who might receive MAiD requests in their workplace, regardless of whether they had participated in MAiD or they were conscientious objectors. In the Spanish context, openly inquiring about such a condition–conscientious objector–may be regarded contrary to the rights of confidentiality and non-discrimination, related to the fundamental right of freedom of belief [21]. Various anti- and pro-MAiD profiles, as well as profiles with doubts were sought, although it was not always possible to know this prior to contact.

This broad spectrum of healthcare professionals was chosen to represent the variability of different profiles and healthcare settings. Special consideration was given to primary care practitioners, as they receive more MAiD requests [2]. Attention was also given to hospital care (trying to include specialists from different services involved, according to the annual reports), and palliative care, as a particular service that serves as a link between hospital care and home care. The recruitment process attempted to achieve a balance in terms of profession (medicine/nursing), gender, and years of experience. Interviewers did not have any close relationship with the interviewees. Although the research was focused on the provision of MAiD in public healthcare facilities, which represent more than the 90% of all MAiD [2], some private centers with hospital or palliative care services were also included to explore potential differences.

Data collection

Different sampling selection strategies were followed to ensure the broadest and most diverse representation. On the one hand, purposive and intentional sampling was applied. The research team’s informal contacts were included (some of them were healthcare professionals, others were people in contact with healthcare professionals due to their teaching and research roles). On the other hand, snowball sampling was used. To respect all perspectives of professionals on MAiD, the interviewees were asked if they knew someone who could meet the criteria defined by the sample design. If a potential participant wanted to know more about the project, the link to the project website was sent to them. Researchers did not report personal interest in the research to the interviewees. In case of acceptance, a research team member contacted by phone or e-mail and arranged an interview. There was no direct relationship with participants established prior to the interviews.

The interviews lasted approximately one hour. During each interview, the script was adopted as an open-ended guide that could be slightly modified depending on the context and profile of the interviewee. We offered participants the option of being interviewed in person or online/telephone. We found no significant differences between the two methods in terms of how the interviews were conducted. Data were collected either at work or at home, with no other presence except for the participant and the researcher. When required, researchers took some specific notes after the interview.

Participants were informed about the study. They voluntarily agreed to participate and be recorded for analysis after signing an informed consent form, which stated that the interview would be pseudonymised, kept confidential, and analysed in aggregated form. They had the opportunity to ask any questions or express any doubts about the study before the interview began, and they received no financial compensation for their participation. Participants were offered the opportunity to receive feedback on the study results once published. The research team took great care to emphasise all aspects of privacy and data management, and to ensure that only the members of the research had access to the information. Interviews were audio-recorded and transcribed. During the data collection, the research team met to discuss data saturation and the need to include/exclude some participants based on whether their profiles were already covered.

Data analysis

The analysis followed a thematic analysis, which emphasises iterative engagement with the data to identify emergent themes that reflect shared and divergent meanings [19]. Additionally, a classification was used to categorise healthcare professionals’ positions on MAiD [18]. The study is reported by the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [22] (Supplementary File 2).

The research was conducted by one male sociologist and six female members of the CONFINES research project, an interdisciplinary group of healthcare professionals, social scientists, and philosophers working in Spanish public universities and research institutions with experience and training in interviewing and qualitative methodology. This team analysed and thematically coded the transcriptions using Atlas.ti vs23, a qualitative data software. Transcriptions were not returned to the participants. A coding tree was created based on the research questions and the field findings, combining closed and emerging categories. In case of disagreement among coders and to avoid biases, the coding team, composed of four researchers, met and discussed the relevance and adequacy of the categories. The coding tree was piloted in the initial interviews and subjected to changes to improve its effectiveness and scope. The final version of the coding tree had 44 codes, plus an emergent open code to capture contributions that were relevant to the study but that could not be included in other codes. Themes were then developed (codes were grouped into eight themes: context, LORE, barriers to applying MAiD, end-of-life interventions, doubts, motives, opinions about conscientious objection, and suggestions). Next, conceptualisation was developed through the interpretation of keywords, codes, and themes. Four main core ideas were identified regarding healthcare professionals’ positions on MAiD (end-of-life care, religion, professional duty, and patient autonomy). According to the discourses on these four core ideas, an interpretative analysis was conducted to classify the interviewed healthcare professionals into four profiles upon their positions and actions: Full Support (FS), Conditioned Support (CS), Conditioned Rejection (CR), and Full Rejection (FR) of MAiD [18]. The main criteria characterising each profile are summarised in Table 3. This classification has enriched the results, by relating them to the healthcare professionals’ positions on MAiD and their perceptions of the Law and the application of MAiD.

Table 3.

Healthcare professionals’ profiles based on their position on MAID

General position on MAID	MAID consideration by case	Willingness to participate in MAID
Full Support (FS)	Strongly in favor	Accepts MAID in all cases that meet legal requirements. Willing to participate fully, including drug administration.
Conditioned Support (CS)	Somewhat in favor	Generally accepts MAID, with possible exceptions. Willingness to participate varies depending on the case.
Conditioned Rejection (CR)	Somewhat opposed	Generally does not accept MAID, with possible exceptions. Willing to participate in the process, except for drug administration.
Full Rejection (FR)	Strongly opposed	Does not accept MAID under any circumstances. Unwilling to participate at any stage of the process.

Results

The information collected was organised according to the profiles of the participants regarding MAiD and along the following discursive axes: healthcare professionals’ assessment of the social impact of the LORE; terminological and conceptual problems of the Law; rights and responsibilities of professionals and patients; MAiD procedure (time limits, role of professionals); professionals’ experiences regarding MAiD; and implementation differences between the Autonomous Communities of the study. The first letter of each verbatim corresponds to the initial of the Autonomous Community; the following refers to the professional profile according to their position on MAiD, as established in Table 3. Discursive differences were found among the Autonomous Communities (Catalonia versus Andalusia and Madrid).

Healthcare professionals’ perspective on the LORE social impact

This section examines the legal safeguards of the provision, the Law’s response to social demand, and the professionals’ perceptions of potential side effects and their expressed commitment to care.

Legal guarantees and response to social demand

According to some participants, the provision of a legal framework contributes to the regulation of a practice that was already being carried out informally.

M2_FS: I think it is lucky to live in a country that has this Law. I mean, it has happened before; people have done it at home and found ways. But for this to be covered by the system seems to me to be an achievement of quality public healthcare that will hopefully last as long as it lasts.

Except for those who are totally opposed to LORE (6 healthcare professionals out of 25 interviewed), the rest of the participants–those who fully support the Law, but also who have a conditioned support or conditioned rejection–believe that it responds to a social demand that allows suffering to be addressed and autonomy over one’s own death to be recognised.

C6_CR: I think that each person has to decide about their life, what they want, but always regulated by Law, well argued, with rules and a sense.

Even from positions of partial rejection of MAiD (5 healthcare professionals out of 25 interviewed), it is noted that the regulation helps to reduce the discomfort of people with high levels of suffering, by increasing the sense of control over themselves.

C6_CR: There are patients who are in the last stage of life who ask for euthanasia. And when they are granted euthanasia approval, the fact that they have control over the situation makes them feel less uncomfortable.

Potential side effects and care commitment

Except among those who fully support MAiD (10 healthcare professionals out of 25 interviewed), there is a consensus on the adverse social effects that LORE could have. Professionals fear that the procedure is a partial response to suffering.

C4_CR: She was 92 or 93 years old, but she did not have […] a terminal organic disease. She did have unbearable suffering, which the Law recognises as such. But she felt that her request was more related to her social fact of loneliness and sadness.

They consider that many requests respond to moments of vital anxiety that could be addressed with interventions and professional support (healthcare, social, etc.).

C3_FS: If the social circumstances were different and the economic circumstances were different, this lady might not have wanted to die, […] now we have an alternative that perhaps bypasses those alternatives and, well, avoids us having to consider where the problem really is.

They suggest that its regulation may divert attention from strengthening other services, such as support for dependent persons, mental healthcare, and particularly palliative care, which requires a holistic approach to care, including, for example, spiritual care.

A3_FR: I understand that an ALS patient, if the patient says they do not want a tracheotomy and a pulmonologist tells them that if they do not get the tracheotomy they will die suffocated, unless there is a palliative care specialist next to them who says: “Don’t worry, the alternative at that moment is that I give you a sedative so that you are calm and you do not feel suffocated and you leave the day you have to leave.” Now, of course, if that second part is not complemented by the first part, the patient says, “Wow, I’m going to die suffocating. I want euthanasia, I don’t want to die suffocated.”

In this regard, it seems that strengthening this type of care would lead to a decrease in euthanasia requests. From this perspective, it is feared that MAiD will become the “quick fix” without social support.

A5_CS: […] it would have been better for me to have had a palliative care Law before a euthanasia Law. If the person has another option or has accompaniment, they might choose something other than euthanasia.

Thus, MAiD is perceived by those professionals rejecting MAiD as a way to avoid care responsibilities. Against this opinion, those who have performed MAiD point out precisely the time and commitment this practice requires.

M3_CS: […] in a consultation in which something as delicate as the provision of MAiD is discussed, you need time and dedication and solemnity, which, if you don’t have time to dedicate to it, can be […] not ethical […].

LORE terminological and conceptual problems

Both profiles of partial support and profiles of partial or total opposition to MAiD share the criticism of certain terms of the Law for their ambiguity. Concepts that delimit access conditions (“unbearable suffering,” “chronic disease”) are questioned as being too vague and subjective.

C4_CR: “Unbearable suffering”, which is what the Law states. It is unclear as a definition. […] The unbearable criterion is set by the patients themselves, not by you, because the suffering is experienced by the person, not the physician.

Likewise, they find problematic the use of “natural death” in death certificates, since it is the result of the administration of drugs intended to cause death.

C5_FR: Ah, another thing, brutal. The Law will consider these people to be dying of natural causes. No, sorry, putting you in a wheelchair and throwing you onto the train tracks is not a natural death.

Opponents of the LORE reject the notion of euthanasia as synonymous with a dignified death. It is argued that people already die with dignity thanks to the support of professionals and that MAiD can be a death of suffering.

C4_CR: That it has been approved and that they talk about dignified death […] it hurts me a lot because that’s a rotten lie. A dignified death is not synonymous with euthanasia, because there have been deaths by euthanasia very traumatic, with a lot of pain.

A criticism shared by both supportive and opposing professionals is that the LORE only considers MAiD in cases of intolerable suffering due to biological alteration, without considering suffering for other reasons (social, existential…). However, their arguments differ. On the one hand, those who support MAiD believe that the Law should include all people who experience that unbearable suffering, regardless of its origin. On the other hand, those who are against it consider this legal limitation to be incongruent and ambiguous.

C7_FS: Euthanasia should be opened up a bit more to a condition not necessarily related to a serious incurable disease. […] Yes, it talks about suffering. But there has to be a situation of functional alteration that causes suffering.

M1_FR: I say, why can I kill a terminal lung cancer patient or someone with ALS as a solution, and not a lady who committed suicide 4 years ago because she was evicted and was 75 years old? Why the terminally ill, yes, and the evicted lady, no?

Conscientious objection

The guarantee of conscientious objection for professionals opposed to MAiD is considered ambivalently. On the one hand, doubts and misinformation are expressed about the conditions for exercising conscientious objection. On the other hand, it is positively perceived that the Law guarantees both the right to MAiD and the possibility of conscientious objection.

A3_FR: I think that the Law does not allow it anymore. I mean, when a case comes to you, if you don’t have a conscientious objection, you have to deal with that case. If it is not signed in advance, you have to deal with it and carry it out.

M7_FR: If guarantees are understood to mean that an objector will not be required to… perform a euthanasia act, it will surely be guaranteed. No one is going to force a professional to perform a euthanasia act….

In contrast, those who are partially or totally in favor of MAiD feel that the LORE is too protective of objectors and puts too much on the shoulders of those who do not object, without considering, for example, mechanisms of care for the latter group or guaranteeing accessibility to MAiD. In some cases, it is suggested that the reasons for objecting are not moral but related to lack of training and information. They even claim that the wording of the Law itself is an “invitation” to object.

A7_FS: […] If you are trained, informed, and supported, it may be easier, and there will be more real objectors and fewer pseudo-objectors.

M3_CS: […] if you look closely at the Law, the responsible physician and the physician who performs euthanasia only have obligations. […] And, from my point of view, the Law can be interpreted as an invitation to be a conscientious objector […].

Rights and responsibilities of professionals and patients in the LORE

There is disagreement about the protection of the rights of professionals and patients in the LORE and the distribution of their respective responsibilities. Those who are totally or partially opposed to the LORE argue that MAiD goes against health and life; therefore, it should not be considered a healthcare service that they should provide.

M1_FR: In general, I am against death as a solution to any problem. I also do not see it as an option that a person has to die to solve an addiction problem, a disease problem, or whatever.

Furthermore, since it is a patient’s request and not a medical indication, they believe that healthcare professionals should not necessarily perform the act.

A9_FR: [Euthanasia] […] is a request from the person rather than an indication from the professional. […] Another discussion that may arise is whether a healthcare professional should do it or could it be a politician, a council member, or a civil servant; why does it have to be a healthcare professional?

There is also discomfort because the Law is perceived to prioritise the patient’s opinion over that of professionals, who should have more influence in the decision-making process. There are interviewees who considered that healthcare professionals have not yet fully embraced patient autonomy in decision-making practice.

A1_CR: Well, one of the reasons that led me to object is that I don’t like the Law. I don’t like the fact that patients come in and demand: “Since it is my right, it is your duty.” And I think it is like that because it is recognised as a right.

C8_FS: […] although we talk a lot about autonomy and the person as the center of attention, in the end, I see that […] the idea that the patient can decide so much, still costs. And even more so when we are talking about life. […] refusal of treatment is still not fully accepted. […] you have to cure, cure, cure….

Those who oppose MAiD believe it is unfair that the demand for MAiD comes from people who are overwhelmed and conditioned by their illness. There are even those who suspect that there are economic interests behind the practice.

A3_FR: But it is unfair to make the patient ask for euthanasia and have to choose as if they were choosing. With ALS and with a symptom that is not controlled, on top of that, to make it look like he is committing suicide, well, I don’t know. It is unfair.

C5_FR: […] these are issues that generate industries behind millions of euros or dollars or whatever, right? Now, a commission has had to be created; […] According to what criteria? Who will be there? Who is going to be paid? What are they going to be paid?

Perspective on the procedure for MAiD

In general terms, it is positively valued, even by those who oppose the Law, that the procedure for MAiD safeguards patients and professionals.

A9_FR: I also know that the Law is rather conservative. I mean, there are many filters and many steps to take before accessing MAiD. And this, well, I like this about the Law.

Specifically, participants highlight the results related to the following procedural aspects: time limits, the figure of the responsible physician, the consulting physician, and the healthcare team.

Time limits

The perception of due dates is not unanimous. On the one hand, it is appreciated that there is time to reflect, carry out the necessary procedures, and assimilate the process, which favors a healthy mourning for professionals. It is also considered positive that the waiting time between the different phases can be shortened in cases where a rapid deterioration of the person is foreseen. On the other hand, some professionals think that the procedure is too slow and may cause unnecessary suffering.

C8_FS: I suppose the bureaucracy makes the process slow, but I think it is still necessary. I agree that there should be a reasonable time to deliberate because it is an irreversible matter… But it is also true that the Law allows you to shorten it if you foresee a loss of capacity soon.

Other participants think it is too fast, given the emotional and bureaucratic complexities involved. Many say that meeting due dates puts pressure on professionals. There is a fear of not meeting them and also of possible dehumanisation through the establishment of closed times.

M4_FS: So, the issue of deadlines also puts a lot of pressure on the professionals involved because it is not easy to meet those due dates and to make sure that everything that is done is done well.

Participants from all levels of care and Autonomous Communities report difficulties related to the lack of time to process and implement MAiD. They explain that the process is complex and involves a commitment and responsibility that is not appreciated, an opinion that is nuanced by satisfactory experiences related to self-management in the workplace.

M3_CS: And somehow, whenever I had to see the patient or, especially, fill out documents, which are not short or few, I did it in my free time. I didn’t have a specific time to do it.

Assessment of professionals’ roles

The lack of prior knowledge of the responsible physician about the person requesting MAiD is considered problematic by some participants. They believe that this role should be filled by someone who knows the patient well to avoid difficulties. They argue that the deliberative process involves the evaluation of complex aspects that require trust and a prior relationship with the person requesting MAiD. In this regard, a general idea is that the request for MAiD should not be associated with a specific medical specialty or service, but with the professional who knows the person best. Prior to the implementation of the Law, there were concerns that this would not be the case and that all the requests would fall on palliative care or primary care services. However, some point out that these concerns have allayed in practice.

M4_FS: I had it easy […] because everything I had discussed with this patient and that family allowed me to do it. But to start a deliberative process with a patient you just met… Buff, you have to take a deep breath.

A1_CR: So, that’s why I say, at first, it seemed like it was all going to go through our hands. But no, it seems that if the patient is not terminal, the palliative care team has no need.

Likewise, communication skills and teamwork are considered necessary to assist in the dying process, especially in those moments of uncertainty.

C8_FS: …what I tell all my colleagues: “When someone comes and asks for aid in dying… you are not alone. We are a team, we will accompany you, we will help you.”

Regarding the functions of the healthcare team, there is criticism of the person who has to administer the medication in MAiD. It is noted that this responsibility should not fall on a member of the healthcare team (usually a nurse) who is only involved in the pharmacological administration and not in the rest of the process, as it is an emotional burden that requires time and reflection.

C1_FS: […] find a nurse who… has nothing to do with it; for that nurse, it must be quite shocking. I have already been with the patient for a while […] but suddenly to find someone, out of nowhere, to also be part of it….

In this sense, the role of nursing in MAiD is debated. There is consensus that the absence of a specific assignment to the figure of the responsible nurse generates discomfort and that it would be appropriate for them to have their place in the process.

A2_FS: The first inconvenience I have seen in the LORE is the figure of the nurse […] does not appear in the place where it should appear, which is in the procedure from the beginning, supporting the responsible physician.

Those who support MAiD are concerned about the figure of the consulting physician. They suggest that their position may condition the process and, if they are against it, that they block it. It is felt that the issuance of unfavorable reports from positions opposed to MAiD could be a problem in the implementation of the Law, causing unnecessary suffering to the patient.

M6_FS: […] obstacles in terms of professionals, since you have to find professionals who respect the decision and move forward because it can also be very delayed. Consulting physicians must be people who know the Law and have a profile that is somewhat aligned with respecting patients’ decisions.

In this sense, a positively valued element is the multi-level evaluation required by the procedure. It is highlighted that the Guarantee and Evaluation Commission then evaluates unfavorable reports issued by the consulting physician. This mechanism is considered to reduce the chances of the result depending on the ideological position of a particular professional.

C8_FS: Out of four cases that the consulting physician said no to, the Commission said yes to all four. What does that mean? That it depends very much on the person, right?

Professionals’ experiences in MAiD

Despite conscientious objections and the fact that it is a complicated procedure, there is a perception that MAiD is generally provided satisfactorily. Participants have a positive view of the role of healthcare professionals, highlighting their professionalism, empathy, sensitivity, and humanity.

M4_FS: […] another thing that gave me enormous satisfaction was to see the involvement of professionals who say yes and take a step forward at that moment, which is a very special moment. How they get involved with the utmost sensitivity and care.

Professionals point out that the bureaucracy of the process is not a real barrier to offering MAiD. Nevertheless, they see a gap between the demands of the population and the different conditions of regional health systems. They point to limitations to the optimal provision of MAiD that need to be addressed, although they cannot be used as an excuse for not providing it responsibly.

A7_FS: […] there is already a confrontation. […] the healthcare system, right? And society. That was the first thing that caught my attention. […] You start to see that there are different speeds in different Autonomous Communities.

Most experiences of the interviewees with the practice of MAiD are positive, highlighting the proper functioning of the procedure and the professional and personal satisfaction derived from accompanying patients at the end of life. Some participants emphasise a positive aspect of not having doubts about the patient’s will. Most of them have felt accompanied and positively valued by the role played by the figures and healthcare teams designated to manage the MAiD process.

A2_FS: For me, it was a relief that the Law was passed […] [MAiD procedure] was a very enriching experience from an ethical, personal, and professional point of view. I mean, it seems to me that it had a very positive impact on my future self.

In contrast, some report a lack of accompaniment, clear indications, and training, generally referring to the first cases of MAiD in Communities with less preparation (Andalusia and Madrid).

A4_CR: Well, the main problem is, of course, the lack of protocols. […] And the gaps, right? […] Because ethical conflicts can arise… There is no training right now that prepares us professionals to face such a case. That was the most stressful thing for me.

Differences in perception in the implementation of the LORE

Participants believe that there are disparities in the implementation of the Law. On the one hand, they identify differences in the ability of citizens to exercise their rights caused by social determinants that show inequities in access to MAiD.

C2_FS: in relation to the social determinants […] I think it is crucial […] People who know the Law and their rights are able to exercise them with freedom, while those who do not have that knowledge, neither they nor their family, are conditioned by other circumstances, right?

On the other hand, they indicate territorial, regional, and local differences, pointing out factors that depend on the healthcare system and the political orientation of each territory (including Autonomous Communities, provinces, and municipalities).

A7_FS: There are different speeds in the different Autonomous Communities. From the beginning, this is noticeable.

Within our interview sample, clinicians in Catalonia more frequently described robust institutional support, whereas those in Andalusia and Madrid generally reported less support. No relevant differences were found in the discourse in these last two communities, so they are presented as a unit of study. The specific aspects of implementation in Catalonia, on the one hand, and in Andalusia and Madrid, on the other, are presented below.

Catalonia

Catalonia is considered by the participants one of the most consistent regions in the implementation of the LORE. The institutional preparation before the entry into force of the Law is emphasised, which gives security to professionals.

C2_FS: I am Catalan and, moreover, well, I think that things have been done exceptionally well in Catalonia, or that is my… Well, it is not only my feeling, but I can objectify it, right?

In primary care, the implementation is considered highly satisfactory. However, difficulties are reported in taking on tasks derived from MAiD. In the hospital setting, difficulties are noted due to insufficient resources, which has made it difficult to meet due dates.

C3_FS: It was a holiday, and there were no beds available. I remember telling the head of service then she said: “Well, there are no beds.”And I said: “Yes, but the day is over. What do I have to do, take her to my home?”

It is positively valued that the responsible physician does not have to be present at the euthanasia act without having to claim conscientious objection. It is possible instead to have another responsible person who is willing to administer the medication for MAiD.

C1_FS: You have the option, which would not be an objection, but to put a second, I don’t know if it was called that, responsible physician, but someone, okay? […] If I don’t want to see that moment, that action, and so on, I have that option, right?

The functioning of a specific support program, the Medical Care Resources Program, which provides technical support for MAiD and a feedback system to improve the procedure, is also perceived positively.

C1_FS: Yes, yes, great support. I am dealing with a case now; if I have any doubt, they call me and say: “Well, I will come to your center the next day, and we will talk about it.” And super well.

Regular meetings with professionals through area referents are beneficial to share knowledge and experience and to raise awareness of the Law among professionals.

C8_FS: I have felt very supported by my [euthanasia] referents for this MAiD. Very well. I have no doubt that they respond very well. In my area, there is no problem.

Other resources that have been highlighted are professional groups in public centers with private management that discuss cases and help alleviate the individual burden and psychological support from the Catalan Institute of Health or the Medical Care Resources Program.

C6_CR: We have a person who supervises us once a month. And, many times, the cases that affect us the most are exposed there […]. And it is a way for us, as professionals, not to be emotionally overloaded and also to listen to the opinion of others in order to do the job better.

Andalusia and Madrid

In Andalusia and Madrid, there is a perception that professionals and citizens are less prepared to apply the Law due to a lack of information, training, and institutional planning.

A6_CS: We are not prepared in terms of training […] I think this has not been made public, what the channels are, how far each specialist can go, the role of each specialist in this aspect. […] We are not prepared for this kind of issue.

This lack of coordination is perceived as a lack of support that also has a negative emotional impact. Some participants reported experiences where they felt pressure and helplessness about the possibility of MAiD being cancelled due to a mistake during the process.

M4_FS: And, well, this person also made me more afraid, afraid of not meeting due dates, afraid that the consulting physician might have known the patient at some point because if he might have known him, then he will reject it because of a formal defect.

Regarding the documentation necessary for MAiD, ambivalence is detected. Some people consider it easily accessible, while for others it is labyrinthine.

A2_FS: “e-professional” is an IT tool we have, where we consult many documents, and in it, as you will see, it says the procedure for aid in dying is stated.

A6_CR: For example, in a section of the SAS website, you can consult everything related to the Law on euthanasia. But that is really not practical. To enter there, you need to have spent time on the website, know the ins and outs….

Discussion

The implementation of the LORE occurs within a landscape of moral, clinical, and institutional complexity, where deeply held values, professional identities, and social expectations intersect [23–26]. Reinforcing knowledge of the Law among professionals and citizens can contribute to sustaining this debate with informed arguments. Besides, listening to professionals is essential to ensure the correct development of the LORE, since the diversity of the profiles interviewed may show different nuances and degrees of acceptance or rejection.

Consistent with other studies, healthcare professionals evaluate the LORE from a broad perspective that goes beyond simply considering a new right for MAiD applicants and new responsibilities for them [27]. As seen, their accounts contemplate technical and legal aspects related to the perception of the Law and its terminology as well as social, institutional, and ethical dimensions of the practice of MAiD. For the sake of clarity, we organise the discussion according to these lines, treated one by one, although we are aware of their interrelation.

Technical and legal aspects

One of the main goals of this article was to analyse the perception of healthcare professionals on the implementation of the LORE and the challenges encountered in the process. Perceived terminological ambiguities in the Law seem to require profound reflection on the healthcare relationship, and the need for effective communication tools and adequate moral evaluation [28, 29]. Some interviewed professionals agreed that the Law’s terminology is confusing.

For example, the certification of MAiD as a “natural death” might cause conflict or misunderstanding. This designation corresponds to the current legal framework in Spain, which distinguishes all deaths, including those from MAiD, from violent deaths or suspected crimes that require judicial intervention. According to the LORE [1] and the Manual of Good Practices in Euthanasia [30], deaths resulting from MAiD are legally classified as “natural”. Then, the Manual specifically regulates the manner in which the death certificate must be issued. Two sections are established: (1) Immediate cause of death: MAiD (Law 3/2021, regulating Euthanasia); and (2) Underlying and primary cause: the underlying pathology–either a “serious and incurable disease” or a “serious, chronic, and incapacitating condition”, which are the legal basis for requesting MAiD—should appear as the fundamental or initial cause. This procedure aims to avoid MAiD cases being carried out without adequate oversight. That said, while the legal rationale and medical codification has been established in this way, in clinical contexts such categorisation may require more than just legal and procedural clarification—it calls for structured dialogue and moral reflection within care teams [30].

The assessment of “unbearable suffering” is another paradigmatic example of legal ambiguity, as noted by several professionals interviewed. Since it is grounded in the patient’s subjective experience, recognition of the patient as a moral agent is crucial to granting credibility to their testimony [31]. Some professionals accept subjective forms of suffering, not always scientifically objectifiable [18, 32]. However, professionals also emphasise the difficulty of distinguishing between suffering that is truly intractable and suffering that may be alleviated through appropriate psychosocial, relational, or palliative interventions [33, 34]. Assessing subjective suffering is inherently challenging, as it cannot be fully objectified or standardized. Doing so calls for refined skills in communication, reflective practice, and relational engagement—capacities that should be fostered through training and institutional support.

Some of the participants perceived the LORE as limiting professional autonomy by placing “too much responsibility” in the hands of seriously ill patients. They are uncomfortable with the demand for MAiD as a right because they believe it is misaligned with the goals of medicine, in line with the results of other studies [15]. Some of them even consider that MAiD should not be carried out by healthcare professionals, since it is not a medical indication, but a personal choice.

Ethical dimensions

As we have seen above, there are technical and legal aspects that raise ethical tensions between respect for autonomy and professionals’ duties of care. This is particularly relevant to pursuing the individual’s best interest under the principle of beneficence and avoiding harm under the principle of non-maleficence. An inadequate interpretation of these principles may lead to the infringement of fundamental values, highlighting the need to incorporate a relational process that enables their careful examination [35, 36].

In the context of MAiD, preserving ethical balance requires that requests grounded in autonomy are not accepted without prior examination of their underlying motivations and the consideration of all reasonable alternatives, in accordance with the principle of beneficence. A central concern in this deliberation is the role of palliative care in addressing the sources of suffering that may prompt such requests. According to Spanish Law (Art. 8.1 LORE), healthcare professionals must engage in a deliberative process ensuring that individuals are fully informed of all available options, including palliative and long-term care. Equally, the principle of non-maleficence demands a comprehensive assessment of potential harms, with particular attention to the undue prolongation of suffering.

This balanced-approach takes autonomy as a relational and context-sensitive capacity, subject to influence from illness, psychological distress, and social isolation [36, 37]. Philosophical and psychological literature emphasises that decisions about dying are often dynamic, emotionally charged, and potentially ambivalent [39–41]. Concretely, the desire to anticipate death is a reaction to suffering in the context of a life-threatening illness, in which the patient sees no other way out than to hasten death [40, 41]. This desire can be expressed spontaneously or after being asked, but it must be differentiated from the acceptance of imminent death or from the wish to die naturally. It may arise in response to one or more factors such as physical or psychological symptoms, existential suffering, or social aspects (e.g., feeling of being a burden on the family), and professionals should adopt a proactive attitude to identify it early [38]. A dimensional approach to suffering (physical, psycho-emotional, social, and spiritual-existential dimensions) facilitates its assessment and management, with the physical sphere being the one that professionals most easily recognize, and the existential-spiritual dimension being the most difficult—particularly in the form of hopelessness, demoralization, and loss of dignity, which is the main reason for requesting MAiD [38–40].

In this regard, recognising the legitimacy of a patient’s account of suffering—especially when rooted in existential, emotional, or relational experiences—demands significant trust and openness from healthcare professionals [41]. It also requires resisting the biomedical paradigm that privileges curing over caring [42], and that often sidelines subjective suffering as less “real” or actionable. Far from diminishing the role of healthcare professionals, acknowledging patients’ narratives reinforces their ethical responsibility: to evaluate not only the presence of disease, but the full scope of human distress [42, 43]. In this sense, the ethical validity of a request for MAiD lies not only in the legal procedures that guarantee informed consent but also in the ability to recognise the credibility of the patient’s account of suffering—even when that suffering is not medically quantifiable [41, 43].

Recognition of suffering as ethically meaningful requires that professionals move beyond strictly biomedical criteria and engage with the patient’s existential, emotional, and psychosocial pain. This recognition is not equivalent to uncritical acceptance; rather, it entails a dialogical relationship grounded in trust, empathy, and responsibility. A healthcare relationship based on recognition of the patient and their needs, and the acquisition of skills such as active listening and assertiveness, is required for a better understanding of MAiD [40, 43, 44]. Approaches like simulation-based learning might be useful for a better self-understanding, as well as patients’ circumstances [45].

This relational perspective allows for a more nuanced understanding of end-of-life choices, one that avoids both naïve libertarianism or clinical paternalism. It also offers an ethical framework in which healthcare professionals are not merely arbiters of eligibility but moral agents who coparticipate in a shared deliberation, sensitive to the complexity and fragility of decision-making under suffering [46].

In this context, the discomfort or hesitation that some professionals express toward MAiD might be interpreted in two different ways: on the one hand, as a resistance to accept the patients’ will, which prioritises a non-relational beneficence [47, 48]. On the other hand, such hesitation may reflect a conscientious effort to attend to the multidimensional nature of patients’ requests, especially when those requests are embedded in suffering that is not merely physical [44, 47].

In both cases, adequate information and training of professionals would help to face the ethical debate raised by MAiD.

In this vein, it is important grounding the discussion on evidence rather than unfounded fears, such as the “slippery slope” arguments [49–53] that warn of potential risks of MAiD and advocate palliative care or dependency support as alternatives [54–56]. While the need for accessible and quality palliative care is clearly recognised [54–58], it does not always address the motivations that lead some patients to request MAiD [46, 58–62]. Reports issued by MAiD Oversight Commission in countries like Canada [63] describe that, in most cases, the individuals who request MAiD are enrolled in both palliative care and long-term care support programs. In Spain, prior to the approval of the LORE, one of the earlier legislative proposals already included data on MAiD requests from patients adequately attended by the Home Care and Support Teams Program (PADES, by its Spanish acronym), showing that opposing palliative care to MAiD amounted to denying the right to individual autonomy and the right to have one’s dignity respected [64]. Therefore, the argument that individuals receiving palliative care would not request MAiD have not been always well founded.

Similarly, the regulation of MAiD in other countries, such as Belgium, the Netherlands, and Luxembourg, fostered further development of national palliative care legislation, against the suspicion that legalising MAiD impedes the growth of palliative care [65]. Thus, MAiD legislation may be compatible with universal access to other options, and different rights and healthcare alternatives can coexist according to individual needs and wishes [48, 59, 63, 66]. Moreover, clear and rigorous safeguards could prevent unacceptable practices where MAiD procedure is regulated by law. In this sense, the LORE has the particularity of adding a third essential filter for approving the practice of MAiD through the Guarantee and Evaluation Commission, which means that all MAiD cases in Spain are obligatorily known to the Commission before the procedure is carried out (Table 1).

Social and institutional aspects

In addition to technical, legal, and ethical aspects, this study shows differences in the LORE implementation across regions (Andalusia, Madrid, and Catalonia). Institutional responsibility is essential in ensuring equitable implementation, especially in primary care—where most MAiD cases occur [2] and which has experienced systemic erosion [67].

Since in Spain health powers are transferred to the Autonomous Communities, it is needed that these Communities function as a key to prevent professionals’ fatigue and to ensure that MAiD is implemented equitably throughout the territory. Although the perceived situation in Catalonia seems to be better than in Andalusia and Madrid, internal differences still need to be improved [6, 17]. Therefore, in addition to the essential commitment of professionals, institutional support is needed to ensure good practice and care for those who provide it.

Differences between patient profiles also reveal inequities, especially for those with degenerative or incapacitating diseases or insufficient socioeconomic support [16, 68, 69]. Thus, we consider that once MAiD has been democratically approved as a right, it is important to avoid inequities in its access. At the same time, it is important to consider that the will to die may be shaped by feelings of being a burden, loneliness, or emotional exhaustion [37–39]. This possibility underscores the relevance of psychosocial evaluation, interdisciplinary coordination, and careful follow-up to guarantee an autonomous decision-making.

Professionals must approach their work as a team and with responsibility, regardless of the level of care. This requires the development of clear regulations that define roles and functions throughout the process, avoiding the current ambiguity [70, 71], not only the aforementioned terminological aspect, but also that relating to the specific roles of the professionals performing MAiD.

The study highlights different experiences between those with institutional support and those managing MAiD processes alone. For instance, the pressure and feeling of unprotection to meet legal due dates varies depending on the degree of support and the professional’s position on MAiD. As a similar study points out [16], good functioning of MAiD should not rely on professional voluntarism.

Besides absolute positions among healthcare professionals of full-support or full-rejection, the findings of this study show that conditioned-support or conditioned-rejection—the gray scale, so to speak—could be a more common position than it might seem [18]. The sample of these partial positions points out that the problems with the LORE may be more linked to emotional or procedural issues (waiting times, bureaucratic burden, etc.) than ideological ones (such as problems of moral conscience), driving to claim conscientious objection as a way to avoid to be involved in MAiD [71]. As it has been declared by some participants and reflected in annual report in Spain [2], sometimes conscientious objection becomes an obstructive behavior which can delay the process and increase suffering for patients and families, a problem observed in Spain [6] and other countries [71]. Therefore, it will be essential to develop training strategies that ensure both the right of individuals requesting MAiD and the proper exercise of conscientious objection by healthcare professionals.

Despite its marginal weight in total mortality (in Spain, 0,0767% in 2023) [2], MAiD raises intense emotional, institutional, and ethical questions. Implementing it responsibly requires not only legal adherence but also ethical vigilance, institutional commitment, and an open acknowledgment of the complexity of end-of-life decisions.

Strengths and limitations

The qualitative approach used in this study has allowed a thorough analysis of key findings related to healthcare professionals’ perspectives regarding MAiD and the differences in implementation across the Spanish territory. It provides detailed and insightful information on an issue that demands ongoing focus and regular updates. However, the study also has some limitations typical of qualitative research, such as its reliance on purposive and snowball sampling, which may limit the ability to generalise the findings to larger populations. As with similar studies [16, 18], the findings have a specific time frame within the initial period of the Law’s implementation. However, the information collected can serve as a reference point for future research. Likewise, this work reflects professionals’ discourses from three Autonomous Communities that, while offering some representativeness in population terms, do not fully show the reality of the rest of the country. Therefore, conducting studies with greater geographical breadth and using different methodologies to establish differences and similarities in applying MAiD would be advisable.

Conclusions

This study contributes to the still limited body of research exploring healthcare professionals’ perceptions of the Spanish euthanasia Law (LORE). While such a Law is widely regarded as a protective one, which safeguards patients and professionals’ rights, the findings also highlight significant challenges in its implementation. Ambiguities in legal terminology, the inherent difficulty of assessing subjective suffering, and the tensions between patient and professional autonomy demand not only technical clarity but also deep ethical reflection and enhanced communicative competence. Training in these areas from a relational perspective may help professionals feel supported in their roles and able to accompany patients with both empathy and critical discernment.

The study also identifies structural inequalities that may limit the effective exercise of the right recognised by the Law. Differences in institutional support, regional disparities, and patients’ social vulnerability can create unequal access to MAiD.

In addition, strengthening clear role definitions, fostering interdisciplinary teamwork, and ensuring access to psychological and administrative support are key measures to prevent healthcare professionals’ overload, and avoid obstructive behaviors disguised as conscientious objection. These elements are essential not only for safeguarding patients’ rights but also for protecting professionals’ integrity and well-being.

Ultimately, this research helps to bridge a critical gap in the literature by offering a situated, practice-based understanding of how the LORE is received and enacted by those who apply it. Its insights are relevant for guiding future policy, professional training, and clinical approaches to MAiD, both in Spain and in other countries grappling with similar debates. Further research—especially using mixed and participatory methods—will be needed to deepen our understanding of the Law’s ethical, clinical, and institutional implications in real-world contexts.

Abbreviations

MAiD

Medical Assistance in Dying

LORE

Ley Orgánica Reguladora de la Eutanasia [Organic Law Regulating Euthanasia]

FR

Full Rejection to Medical Assistance in Dying

CR

Conditioned Rejection to Medical Assistance in Dying

CS

Conditioned Support to Medical Assistance in Dying

FS

Full Support to Medical Assistance in Dying

Biographies

Rosana Triviño-Caballero

is an associate professor of Bioethics at the Faculty of Medicine of the Universidad Complutense de Madrid. She is PI of the research project CONFINES and member of INEDYTO. 

Mª Teresa López de la Vieja

is a Professor Emerita of Philosophy at the Universidad de Salamanca and member of the research project CONFINES. 

Isabel Roldán-Gómez

is assistant professor of Bioethics at the Faculty of Medicine of the Universidad Complutense de Madrid. She is a member of the research projects CONFINES and INEDYTO.

Mª Isabel Tamayo-Vázquez

is a professor of Bioethics at the Andalusian School of Public Health, member of the research projects CONFINES and INEDYTO, and member of the IBS.Granada.

Tayra Velasco-Sanz

is associate professor of Bioethics at the Faculty of Nursing of the Universidad Complutense de Madrid and member of the research project CONFINES. 

Authors’ contributions

The first author is listed based on contribution; all subsequent authors appear in alphabetical order. All listed authors were involved in the conception and design of the study and in the interpretation of the results. In collaboration with other members of the CONFINES research team and the Social Research Cooperative APLICA, MI Tamayo, TR Velasco, and R Triviño contributed to fieldwork and data collection. TR Velasco and MI Tamayo were responsible for preparing the tables. I Roldán, MT López de la Vieja, and R Triviño compiled the bibliography. R Triviño, together with other members of CONFINES and APLICA, had a substantial participation in the critical analysis of the coding process; she drafted the initial version of the manuscript and its subsequent revisions incorporating the contents and feedback provided by the rest of the authors; and she prepared the COREQ checklist. All authors critically reviewed the manuscript and approved the final version for publication.

Funding

This work has been developed in the framework of the following research projects: the project INEDyTO 3 (PID2024-161389OB-I00 funded by MICIU /AEI /10.13039/501100011033 / FEDER, UE) and CONFINES (code FD9/21_03), funded by the Programa de Ayudas a Proyectos de Investigación Científica 2021 (BBVA Foundation).

Data availability

The datasets generated and/or analysed during the current study are not publicly available to preserve participants’ privacy, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The research has been approved by the Research Ethics Committee of the Complutense University of Madrid (Spain) the 12nd of September 2022 (Ref: CE_20220915-13_HUM). The ethical principles of the Declaration of Helsinki were followed. Regarding the protection of the personal data of study participants, Organic Law 3/2018 of December 5, on the Protection of Personal Data and the Guarantee of Digital Rights, as well as any applicable regulations that continue to apply pursuant to the sole repealing provision of the aforementioned law, apply.

In accordance with the project report, the authors declare that the following ethical aspects were complied with in all phases of the project:

Exhaustive information to the participants about the objectives and methodology of the study.

Informed consent process. They were given an information sheet and time to ask for questions; doubts were answered; they were informed of the voluntariness of participation and the possibility of withdrawing from the study without negative consequences. They also gave their consent to participate in the study and to publish the results derived from it. 

Maintenance of the confidentiality of the information and custody of the data collected in accordance with the Organic Law 3/2018, of December 5, 2018, on Personal Data Protection and guarantee of digital rights (LOPD-GDD).

Attention to a potential emotional impact of the interview on the interviewee (by managing the interview and providing information on support resources).

Return of the future results to the interviewees.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.