assisted death, assisted suicide, nurse, palliative care, scoping review, voluntary euthanasia



  1. Suva, Grace MN, RN
  2. Penney, Tasha MN, RN
  3. McPherson, Christine J. PhD, RN


In June 2016, Bill C-14 or Medical Assistance in Dying legislation became law in Canada. With this law came changes to nurses' (ie, nurse practitioner, registered nurse, registered practical nurse) scopes of practice, roles, and responsibilities. While federal law, regulatory, and organizational policies are developed to inform nurses about the practice of medical assistance in dying, there is little evidence examining how nurses' roles and responsibilities are enacted in practice. Therefore, a scoping review was conducted to synthesize the evidence on nurses' roles and responsibilities in relation to medical assistance in dying and to identify gaps in the literature. A secondary aim was to identify organizational supports for nurses to effectively and ethically engage in medical assistance in dying. Using a recognized and rigorous scoping review methodology, the findings from 24 research studies were synthesized in this article. The analysis highlights the importance of effective health care professional engagement with the individual in the decision-making process and of the need to educate, support, and include nurses in providing medical assistance in dying. Overall, the current research on medical assistance in dying is limited in Canada, and more attention is needed on the role of the nurse.


Article Content

The passing of federal Medical Assistance in Dying (MAiD) legislation (ie, Bill C-14) in June 2016 made it legal in Canada for physicians and nurse practitioners (NPs) to assist individuals meeting certain criteria to request and receive assistance to end their lives.1 Federal MAiD legislation created alignment between Canada and a growing number of jurisdictions with similar legislation. In countries such as the Netherlands, Belgium, and Luxembourg, for example, voluntary euthanasia (VE) and physician-assisted suicide (PAS) is legal, and PAS is permitted in 8 states in America.2-4 Physician-assisted suicide, also known as physician-assisted death (PAD), refers to the voluntary self-administration of medications prescribed by a physician with the specific purpose to cause death.2 Voluntary euthanasia differs from PAS and PAD in that the physician administers the lethal medication on the direction of the individual making the request to end life. Although PAS (ie, the voluntary self-administration of lethal medication prescribed by a physician with the specific purpose to cause death) has been legal in the Canadian province of Quebec since 2014,5 Canadian MAiD law expanded on Quebec's Bill 52 by broadening the eligibility criteria, extending the practice to include the rest of Canada, and developing a role for NPs in both prescribing and administering medications to cause death.1 Under the Canadian criminal code, VE and PAS became collectively known as MAiD. Medical assistance in dying is defined as the administration of a substance to an individual, at his/her request, to cause his/her death, and the prescription or provision of a substance to an individual, at his/her request, so that he/she may self-administer the substance.1 Regulations governing the practice of MAiD are strict to safeguard the public and the health care professionals (HCPs) involved. To be eligible for MAiD in Canada, an individual must have "a grievous and irremediable medical condition" and be 18 years or older, competent to voluntarily provide informed consent with knowledge of alternatives to MAiD, and entitled to Canadian health care services.1 Furthermore, individuals who are eligible for MAiD need to have an advanced, incurable condition with significant incapacity and experience intolerable suffering.1 Individuals who meet the criteria for MAiD usually have underlying health conditions that are progressive and life limiting and needs that are complex with significant psychosocial, physical, and existential impact arising from their health.6 Based on data collected from jurisdictions where MAiD is permitted, the predominant underlying medical condition of individuals seeking MAiD is advanced cancer and then progressive neurological conditions.6


The vast majority of individuals with progressive, life-limiting conditions will not seek assistance to end their lives. Estimates from jurisdictions where MAiD is legally permitted indicate rates between 0.3% and 4.6% of all deaths.7 In Canada, from January 1, 2017, to June 30, 2017, approximately 0.9% of all deaths were attributable to MAiD.8 Instead, individuals with progressive, life-limiting conditions are likely to benefit from a palliative approach to care, where the emphasis is on alleviating suffering and enhancing quality of life.9 The widespread recognition of the benefits of palliative care has led advocates both for and against MAiD to call for improvements in access to palliative care services.10,11 Consequently, Canadian MAiD law stipulates that individuals considering or requesting MAiD must be offered alternatives such as palliative care or other health care services.1 Moreover, the federal criminal code does not allow HCPs to solicit or encourage an individual to end one's own life.12,13


However, MAiD is viewed as a viable option to end suffering for a small proportion of individuals who consider their progressive, life-limiting condition intolerable, with intervention alternatives that they deem unacceptable.14 Indeed, in a health care climate that values autonomy in health care decision making, legislative acceptance of MAiD has come to epitomize the right to self-determination on the grounds of compassion. Research aimed at understanding the motivations for requests for MAiD indicates that the underlying issues are multifaceted and interactive, culminating in the experience of suffering. Although suffering is by no means limited to the existential and psychological domains,15 it is psychological distress and losses associated with the meaning attributed to the illness and its consequences (eg, illness-related symptoms and declining functioning), such as loss of sense of self, loss of hope, loss of dignity, and the sense of being a burden to others, which emerge from the literature when discussing intolerable suffering and MAiD.14 Nurses play a pivotal role in the provision of palliative care to individuals with life-limiting, progressive illness to meet the myriad of issues that can create suffering. The timely identification of individuals in need of palliative care, comprehensive assessment of an individual's needs, and implementation of interventions are integral parts of palliative nursing care that can alleviate suffering and promote quality of life.


The debate surrounding MAiD legislation remains a contentious ethical and moral issue. For the nursing profession, the involvement of nurses in MAiD has been largely interpreted from a principle- or care-oriented approach to ethics.16 The principles of respect for autonomy, nonmaleficence, beneficence, and justice have been used to both support and challenge MAiD as part of nursing care and as a legal service.16 Despite the grand debates on MAiD, nursing bodies have been largely silent in their involvement in these debates.17 Nonetheless, nurses are challenged to deal with the reality of the law as it stands on MAiD and its implications to their practice, personal, and professional ethics.16 Although the federal legislation on MAiD has implications for all nurses, those who care for individuals with progressive, life-limiting health conditions and their families are most likely to be affected by the MAiD law. Specifically, albeit not exclusively, it is in palliative care and oncology programs where nurses are most likely to identify individuals who seek MAiD.6,7 Nurse practitioners would have the authority to assess and evaluate a person's eligibility for MAiD. Registered nurses and registered practical nurses may be involved in supporting the NP or physician with tasks to prepare an individual for MAiD (eg, inserting an intravenous line, communication, and support to the individual and family).


In Canada, the extended scope of NPs' practice with regard to MAiD is new.1 Switzerland is the only other country that permits nurses (or nonphysicians) to administer medications directly to individuals for assisted suicide.18 A legal framework provided by regulatory nursing bodies and the national-level Canadian Nurses Association (CNA) guides and directs nurses' roles and responsibilities with respect to federal MAiD legislation.19 For example, the CNA stipulates that NPs have a role in MAiD that is distinct from other nurses (eg, establishing a person's eligibility, administering or prescribing the medication), and as such, the scope of the nurses' role and associated responsibilities needs to be well understood in relation to Canadian MAiD law.19 The CNA provides nurses with a generic pathway to facilitate the understanding of MAiD legislation.19


Since the legalization of MAiD in Canada, nurses have been directly involved in MAiD services. However, little is known about how nurses enact their roles with MAiD, which is considered to be a highly emotive and morally challenging aspect of practice. A recent qualitative synthesis of what is morally at stake for nurses caring for individuals who make requests for MAiD identified the parallels between nurses' everyday moral experiences when caring for individuals at the end of life and the "exceptional" practice of MAiD.20 The review raised awareness of the moral issues nurses encounter in their practice as they relate to MAiD and the care of individuals who are dying.20


Nurses who contentiously object to MAiD do not have to be involved in MAiD services. However, this does not absolve nurses of their professional obligation to individuals in their care. Regardless of nurses' values concerning MAiD, they do express a moral responsibility toward individuals who request MAiD20 or want to be involved in the decision-making process.21 Notwithstanding, all nurses have a professional obligation to provide nursing care to individuals at the end of life and to facilitate access to palliative care and other services.19 For nurses to meet their professional obligations, they need to be knowledgeable and skilled in dealing with requests for MAiD and prepared to ethically engage with individuals to navigate MAiD and understand their role concerning the provision of MAiD services.


A key question is: How are nurses' roles and responsibilities effectively and ethically enacted in regard to the practice of MAiD? To answer this question, the authors conducted a scoping review to identify, synthesize, and describe the research literature pertaining to the nurses' role in MAiD and the organization- and system-level supports that are needed to facilitate this process.



A scoping review refers to a systematic method of searching, selecting, and synthesizing knowledge (eg, mapping key concepts, identifying gaps in the literature) for an exploratory research question in a defined area or field.22 It was appropriate to use the scoping review methodology because the research on the nurses' roles and responsibilities in MAiD is limited in Canada. It was important to confirm the scarcity of the Canadian literature and then delve into the international research to provide additional evidence to support the nurses' roles and responsibilities in Canada, where the practice of MAiD is in its infancy. Thus, literature from outside Canada was included if the evidence was generalizable or transferable to the nurses' scope of practice in Canada. The primary purpose of this scoping review was to use a rapid method to map the existing literature on the roles and responsibilities of the nurse in MAiD and, as a secondary aim, to identify organizational supports required by nurses to effectively and ethically provide this legal service.


The scoping review methodology was guided by Arksky and O'Malley's23 framework, which is recognized as a rigorous approach to the process and reporting of scoping reviews. Arksky and O'Malley's23 scoping review framework includes 5 key stages: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing, and reporting the results.


Identifying the Research Questions

The research questions that were developed for this scoping review were informed by clinical practice and Canadian gray literature on MAiD (ie, nonstudy articles from credible organizations), from sources such as the CNA, College of Nurses of Ontario, and the Government of Canada. The authors of this article determined that it was necessary to ascertain the overall breadth of the evidence available on the nurse role in MAiD, and the organization- and system-level supports needed by nurses to implement MAiD legislation. Thus, the research questions that guided this scoping review were as follows: (1) What is the role of the nurse in MAiD for individuals at the end of life? (2) What organization- and system-level supports are needed by nurses to be able to provide MAiD as an option for individuals at the end of life?


Identifying Relevant Studies

To capture the most up-to-date literature, English-language, primary research studies published between January 2011 and August 2016 were searched in the following databases: MEDLINE, MEDLINE In-Process/Epub, EMBASE, and Cumulative Index to Nursing and Allied Health. Because MAiD law continues to evolve in Canada and around the world, a 5-year time frame was chosen to capture the most current, relevant literature to inform nurses' roles and responsibilities in MAiD. The search strategy included all research study designs (eg, primary studies, quantitative, qualitative, reviews). In February 2018, the authors updated the search to include the most current literature before the publication of the scoping review, using Arskey and O'Malley's23 scoping review methodology.


Key terms used to capture MAiD included MAiD, assisted suicide, euthanasia, right to die, wish to die, and dying and dignity. Key terms used to define the role of the nurse in relation to the dying individual included nurse role, health personnel, attitude of health personnel, professional role, professional-patient relations, nurse-patient relations, and nurses' practice patterns. In order to mitigate the risk of excluding articles that could apply to the role of the NP or registered nurse in Canada, the search strategy was tailored to capture the MAiD practices of other health care providers such as physicians.


Study Selection

At the time of the scoping review, the Government of Canada's definition of MAiD was used to guide the development of the inclusion/exclusion criteria.1 Research studies were included if they met the following eligibility criteria: focused on MAiD for adults (>=18 years) across all health care settings, published in the last 5 years (ie, 2011-2016 with updates to the end of 2017), published in English, and identified as a primary research study (ie, all research designs were included in the scoping review). International research studies were also included if the concepts of the nurse role in MAiD could be applied to the nurses' scope of practice in Canada.


Research studies were excluded if their definition of VE, PAS, PAD, or MAiD did not align with the definition of MAiD as defined by the Government of Canada.1 Thus, the following topics were excluded from the scoping review because they differed from the Canadian definition of MAiD: palliative/deep sedation, hastening death, and withdrawal of lifesaving interventions. Research studies were also excluded from the scoping review if they explored MAiD issues/challenges for individuals with mental illnesses (eg, depression, dementia, etc), focused on the MAiD debate (eg, whether to legalize MAiD, the relationship between MAiD and palliative care), explored nurses' "willingness" to assist with MAiD in countries where it was not a legal service, or explored the attitudes of HCPs on MAiD and public opinion on MAiD.


Screening and Relevance Review

Two master's degree-prepared registered nurse program managers (PMs) trained in scoping review methodology were assigned 1 of 2 research questions. The inclusion/exclusion criteria and a 2-step process were used by each PM, to independently screen the research studies. First, the PMs independently reviewed the titles and abstracts of potential research studies. Second, the research studies deemed potentially relevant to their assigned research questions underwent independent full-text review by the 2 PMs. Research studies that the PMs were unsure of with respect to their relevance to the scoping review were discussed with the research team until consensus was reached.


Charting the Data

Pertinent information from the included research studies was extracted into data tables and organized by research question. The data tables included information on the purpose, study design, characteristics of the sample, results, key findings, and limitations. Quality appraisal was not done because the purpose of the scoping review was to map the existing literature to determine the overall breadth of the current research on the nurse role in MAiD and the organization- and system-level supports needed by nurses to implement MAiD.


Collating, Summarizing, and Reporting the Results

To synthesize the literature and describe and address the purpose of this scoping review, the PMs organized the research into themes around the research questions. The PMs developed narrative reports to provide a concise synthesis of the themes. Information on the characteristics of the studies (eg, study design, study setting, and target population) and comments on the overall consistency of the evidence and study limitations were included in the narrative reports. The themes derived from our synthesis were collectively agreed upon by the research team.



The literature search yielded 8406 records. Of these, 8190 records were excluded because they did not provide actionable recommendations to nurses or organizations to further inform nursing roles and responsibilities or the supports needed by nurses with MAiD. After full-text review, 20 studies met the inclusion criteria. The research designs of the studies included in the scoping review varied considerably: cross-sectional (n = 9), qualitative (n = 8), mixed methods (n = 2), and case-control (n = 1). The countries of origin of the research studies were also diverse and included the Netherlands (n = 9), Belgium (n = 4), Brazil (n = 1), Croatia (n = 1), United States (n = 4), and Canada (n = 1). Overall, the majority of the research studies were conducted in countries where MAiD is law and well established (ie, the Netherlands and Belgium).


The search for additional literature between 2016 and December 31, 2017, yielded 1191 records. Following the screening of the study titles and abstracts, 23 studies received a full-text screening for potential inclusion in the scoping review. Of the 23 studies identified, only 4 articles met the inclusion and exclusion criteria. All 4 studies used qualitative research designs. The countries of origin for the research studies were Canada (n = 1), Switzerland (n = 2), and the Netherlands (n = 1). These 4 studies were incorporated into the scoping review themes.


Thematically, the 24 research studies included in the scoping review focused on effective engagement with an individual who requests MAiD, the decision-making process, the need for education and increased awareness on MAiD, and the need for the support and inclusion of nurses with regard to providing MAiD services as an option for individuals at the end of life.


Health Care Professional Engagement With an Individual Who Requests MAiD

In total, 6 studies addressed the topic of HCPs engaging with individuals who seek MAiD.24-29 Although 5 of 6 studies did not directly address the role of the nurse with respect to an individual's engagement with MAiD, evidence that could apply to nurses was identified (ie, studies with physicians). According to 5 studies, effective engagement with an individual that is initiated and facilitated by the physician is key to the decision-making process with MAiD. The literature identified a number of barriers and facilitators to effectively engage individuals in discussions on MAiD. Key facilitators included strong physician-individual relationships,24 open communication between the physician and individuals seeking MAiD,25 and communication by the physician that conveys empathy and provides clear boundaries and opportunities for organizing and expressing one's thoughts and feelings.26 Key barriers included physicians not initiating conversations on death and dying27 and physicians' use of modal verbs.28 Dieltjens et al28 specifically investigated the modal verbs used by physicians that express "volition, obligation, possibility, and permission" during an individual's explicit request for MAiD.28 This study revealed that the physician's use of a patronizing and less appreciative attitude toward MAiD was a key barrier to effectively engaging with individuals requesting MAiD.28


The 1 study that examined nurses' engagement with individuals seeking assistance to end their lives was conducted in Quebec, Canada. At the time of the study, Canadian MAiD legislation was not in effect. However, the findings have relevance as the researchers sought to explore oncology nurses' interactions with individuals who desired a hastened death.29 In this study, it was found that nurses' engagement with individuals expressing the desire for death often started with a need to understand an individual's request.29 To do this, nurses expressed a need to be therapeutically present with the individuals.29 However, therapeutic relationships were difficult to establish because of a number of reasons, including nurses' comfort with difficult conversations about an individual's desire for a hastened death, when nurses questioned the efficacy of their presence, skills, and abilities during an individual's suffering, and when nurses were not given sufficient time to properly engage with the individual.29


Decision-Making Process

In total, 9 studies addressed the topic of decision making and MAiD.24,26,30-36 One study addressed the role of the advanced practice nurse in making decisions on MAiD.30 In this study, advanced practice nurses were more likely to act on a request for MAiD if individuals at the end of life were perceived to be in pain and physically suffering from a life-limiting, progressive illness.30 The remaining 6 studies investigated the role of physicians in the decision-making process in relation to individuals who chose MAiD and their relatives.24,26,31-34 Overall, the decision to pursue MAiD is a dynamic and complex process that involves the interplay of individual, relative (ie, family), and physician preferences or factors that influence the final decision on MAiD.24,26,30-34


The literature identified a number of factors that influence the decision-making process with individuals seeking MAiD. A case-control study of 55 participants who requested MAiD and 39 participants with advanced illness who did not request MAiD concluded that depression, hopelessness, dismissive attachment, and lower levels of spirituality characterized individuals who were more likely to request MAiD.31 Dismissive attachment refers to an individual who is independent and self-reliant, whereas spirituality refers to how an individual defines meaning, purpose, and hope in his/her life.31


Two additional research studies identified characteristics that lessened an individual's probability of meeting eligibility criteria, including not being fully competent, unbearable suffering "to a lesser extent,"32 being tired of life, depression, and not wanting to be a burden on others.33 On the other hand, individuals who were older33 and who were physically suffering30,33 were identified as more likely to meet MAiD criteria and influence an HCP's intention to act on a MAiD request. However, not all requests for MAiD are followed through by the individual who makes the original request. According to a qualitative study of 205 general practitioners who dealt with MAiD requests in Belgium, an individual's wish to die was less likely to be about an explicit wish for death, but rather a reflection of an individual's fears of death and dying.34


There is a series of physician-related factors identified in the literature that influence the decision-making process on MAiD. First, it is essential that physicians assess individuals according to the legal eligibility criteria for MAiD. A study of 36 physicians from the Netherlands and the United States, a study of 205 general practitioners from Belgium, and a study involving 33 Dutch general practitioners all concluded that the law shaped their decisions.24,34,35 Some of these same studies also stated that the decision-making process was influenced by whether the physician considered MAiD as part of their role,24,36 whether the physician conscientiously objected to MAiD (ie, MAiD did not align with one's moral beliefs and values),24,34,36 and if the physician anticipated negative emotional and psychological distress because of one's participation in MAiD.36 Second, the quality of the physician's relationship with the individual seeking MAiD was identified to be important in the decision-making process in 3 studies. More specifically, a strong relationship between the physician and individual is needed to be able to perform MAiD35 or to thoughtfully balance the individuals's options at the end of life and to continue quality palliative care even if a request for MAiD is declined.26,32


One study that interviewed 28 Dutch physicians and 26 relatives of loved ones who died of MAiD and 1 study of 33 Dutch general practitioners identified the influence of individuals' relatives on MAiD decisions.32,35 More specifically, physicians were less likely to grant MAiD if they thought that the family would not cope well with the individual's death as a direct result of MAiD. For some physicians, it was also important that family members agreed with MAiD.35 Thus, relatives should not be overlooked in the decision-making process.


Education and Increased Awareness of MAiD

In total, 7 studies concluded that nurses require education, training, and increased awareness of MAiD.21,30,37-41 The majority of the literature for research question 2 provides direct evidence on the supports needed to facilitate the nurses' role in MAiD. This contrasts the physician-focused literature identified in research question 1, wherein concepts related to engaging the individual seeking MAiD in the decision-making process can only be indirectly applied to the nurse role. Two studies identified the need for organization-wide education, training, and clear guidelines for nurses when approached with an individual's request for MAiD.37,38 Six studies identified specific areas for additional education and training including the clinical implications of end-of-life practice legislation21,39; ethical codes of conduct and application of MAiD to real-life situations30; policies and procedures on MAiD40; rights, professional roles, and boundaries of HCPs and users of MAiD services21,41; decision making and practices in relation to MAiD21; end-of-life and palliative care issues; the opportunity for discussion including a forum to talk about "professional mission and deontology"; and reflective practice.38


Support and Inclusion of Nurses

Four studies concluded that nurses need to be supported and included in the provision of MAiD services for individuals who seek this service at the end of life.30,40,42,43 All 4 studies provided specific leadership and/or organization-level strategies to support nurses with MAiD.30,40,42,43 For example, a study of 100 nurse leaders in California determined that organization-wide education, policies, and procedures that promote ethics and teamwork in end-of-life situations are needed to support nurses in clinical practice.42 Similarly, using an ethics policy on euthanasia, both as an organizational tool and as part of a dynamic process, was identified as an important finding in a study by Lemiengre et al43 that reviewed institutional ethics policies on MAiD.43


The study by Lemiengre et al43 also recommended that administrators and ethics committees create a climate that supports HCPs who encounter ethical dilemmas in clinical practice. This finding is similar to another study by Feldt et al,40 wherein directors of nursing in long-term-care homes identified the importance of keeping the lines of communication open from top management to frontline HCPs to create an environment that is supportive and responsive to nurses' needs. As leaders and patient advocates, nurse managers also need to be aware of the intentions of nurses and other care providers, as well as the individuals they care for, when collaborating in discussions on MAiD and implementing MAiD practices.30 An increased awareness of where nurses are positioned with respect to MAiD can impact daily care and general flow.30 Thus, an awareness of nurses' stance on MAiD enables nurse managers to better serve the individuals who may qualify for MAiD services in the future.30



The purpose of this scoping review was to identify and summarize the evidence regarding the roles, responsibilities, and supports available to nurses with respect to MAiD in Canada. The scoping review identified only 24 articles, the majority of which were internationally published. The evidence on the roles and responsibilities of nurses and MAiD was mainly informed by research done on the dynamic interplay between physicians, individuals at the end of life, and their families with MAiD. The current literature suggests that effective communication and strong relationships between the individual, health care provider, and family are key in the decision-making process and in the final decisions made to act on MAiD requests.24-26 However, there is a paucity of evidence as to what can be done to act on the barriers and facilitators to effective communication, decision making, and therapeutic relationships with individuals who request MAiD and their families. This conclusion is further supported by the scoping review evidence that suggests that organizations currently provide inadequate education and supports for nurses involved in MAiD services.37


The scoping review evidence needs to be interpreted within the broader context of nursing and the provision of palliative care services for individuals at the end of life. In Canada, approximately 0.9% of individuals received MAiD between January 1, 2017, and June 30, 2017.8 Thus, the majority of individuals at the end of life seek other interventions for their suffering. The nursing profession plays a key role in supporting individuals with life-limiting, progressive illness, including the capacity to assess and attend to an individual's existential and spiritual needs and explore an individual's motivations for MAiD, if this is a request. Thus, in the MAiD literature, the role of the nurse within the broader context of care provided to individuals who are living with progressive, life-limiting illness needs to be further explored. For example, further evidence is needed on how to address the nurses' right to conscientiously object to MAiD. Additional research to understand the nurse role as a member of the health care team to support individuals at the end of life and their families is also needed. Nurses as part of the health care team are in an opportune position to support individuals when a request for MAiD is denied and to support families when a loved one requests or goes through with MAiD. Additional research is also required to further explore the impact of MAiD on nurses' mental health (ie, moral distress, compassion fatigue).


The NP role requires further exploration in order for the nursing profession in Canada to play a larger role on the health care team in the provision of MAiD services. Currently, there is a paucity of evidence on the role of the NP with regard to their ability to assess an individual's eligibility for MAiD, engage in the decision-making process, and provide MAiD services. However, further research investigation is challenged by the evolving NP role, variations in MAiD processes across Canada, and the differences in how nursing roles and responsibilities are enacted within the MAiD legislative framework.


There are a number of methodological limitations. The authors acknowledge that the majority of the studies identified in the scoping review are outside Canada. However, the themes identified from the analysis of the literature can be transferred to the Canadian context. The literature search for this scoping review also went back 6 years in total (ie, 2012-2016 with an update to the end of 2017). However, because MAiD is a new and evolving topic, it was important to review the most up-to-date evidence that could apply to current nursing practice. The research studies included in the scoping review were also not quality appraised. However, scoping review methodology as outlined by Arksky and O'Malley does not necessitate a quality review of individual studies because the primary objective is to scan the literature and ascertain the breadth of the research in an area of focus.23 The 1 substantive limitation of the scoping review is that it captured English-only studies. Thus, there may have been relevant literature that was not included in the final scoping review results. However, the authors are confident that the current scoping review is inclusive of the current literature on MAiD.


In Canada, the implementation of federal MAiD law (ie, Bill C-14) requires national, provincial, and territorial-specific evaluation with the identification of short- and long-term evaluation measures that are meaningful to the individual, the family, and the health care system. Currently, different jurisdictions use different mechanisms to access and provide MAiD services. Moreover, there is no standard of care for the provision of MAiD services or best evidence to underpin current processes. The development and collection of process and outcome measures with respect to the access and delivery of MAiD services across Canada are necessary to identify the processes most effective in accessing and coordinating MAiD services for dying individuals.



The evaluation of Canadian MAiD legislation and its impact on nurses and individuals at the end of life who choose this service and the families who will remain long after the service has been delivered is uncertain. Current evidence provides some insight into the nurses' role in MAiD, including the importance of HCPs' effective engagement with the individual in the decision-making process. At the organizational level, there is a definite need to educate, support, and include nurses in providing MAiD services to requesting individuals. Additional in-depth research on nurses, their involvement in MAiD processes, how they navigate this service for individuals at the end of life, and the moral distress involved in MAiD processes is needed. However, this scoping review does point to the current gaps in the literature and highlights the nurses' need for further involvement, education, guidance, and support to effectively and ethically engage with individuals who chose MAiD at the end of life. It is important to understand that Canadian MAiD legislation (ie, Bill C-14) continues to be in effect despite the very limited literature on the nurses' role in MAiD. Nurses need to understand that MAiD law in Canada precludes nursing from soliciting or encouraging anyone to end his/her life. The nursing profession has a duty to ensure that all nurses are protected and fully understand the law on MAiD, given that the evidence is virtually absent and the fact that the law takes priority when following through with an individual's request for MAiD.



The authors thank Lesley Hirst, MSc, MN, RN, chief of nursing practice, Hamilton Health Sciences, and cochair of the End of Life Care in the last 12 months: Adults with life-limiting and progressive illness, for her valuable review of the manuscript.




1. Government of Canada. Legislative Background: Medical Assistance in Dying (Bill C-14). Ottawa, ON, Canada: Her Majesty the Queen in Right of Canada; 2016:1-55. [Context Link]


2. Deliens L, van der Wal G. The euthanasia law in Belgium and the Netherlands. Lancet. 2003;362(9391):1239-1240. [Context Link]


3. Watson R. Luxembourg is to allow euthanasia from 1 April. BMJ. 2009;338:b1248. [Context Link]


4. Steinbrook R. Physician-assisted death-from Oregon to Washington State. N Engl J Med. 2008;359(24):2513-2515. [Context Link]


5. Quebec National Assembly. Bill 52: An Act Respecting End-of-Life Care. Quebec, QC, Canada: Quebec Official Publisher; 2013:1-20. [Context Link]


6. Blanke C, LeBlanc M, Hershman D, Ellis L, Meyskens F. Characterizing 18 years of the Death With Dignity Act in Oregon. JAMA Oncol. 2017;3(10):1403-1406. [Context Link]


7. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79-90. [Context Link]


8. Health Canada. 2nd Interim Report on Medical Assistance in Dying in Canada. Ottawa, ON, Canada: Her Majesty the Queen in Right of Canada; 2017:1-14. [Context Link]


9. World Health Organization. WHO Definition of Palliative Care 2017. Accessed April 22, 2018. [Context Link]


10. Dyke AJ, Hollinger DP. Life's Worth: The Case Against Assisted Suicide (Critical Issues in Bioethics). Cambridge, UK: Wm. B. Eerdmans Publishers; 2002. [Context Link]


11. Quill TE, Battin MP. Physician-Assisted Dying. The Case for Palliative Care and Patient Choice. Baltimore, MD: The John Hopkins University Press; 2004. [Context Link]


12. College of Nurses of Ontario. Guidance on Nurses' Roles in Medical Assistance in Dying. Toronto, ON, Canada: College of Nurses of Ontario; 2017:1-8. [Context Link]


13. The College of Physicians and Surgeons in Ontario. Medical Assistance in Dying. Toronto, ON, Canada: The College of Physicians and Surgeons in Ontario; 2016:1-10. [Context Link]


14. Dees M, Vernooij-Dassen M, Dekkers W, van Weel C. Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: an integrative review. Psychooncology. 2010;19(4):339-352. [Context Link]


15. Cassell EJ. The Nature of Suffering and the Goals of Medicine. New York: Oxford University Press; 2004. [Context Link]


16. Quaghebeur T, Dierckx de Casterle B, Gastmans C. Nursing and euthanasia: a review of argument-based ethics literature. Nurs Ethics. 2009;16(4):466-486. [Context Link]


17. Monteverde S. Nursing and assisted dying: understanding the sounds of silence. Nurs Ethics. 2017;24(1):3-8. [Context Link]


18. Hurst SA, Mauron A. Assisted suicide and euthanasia in Switzerland: allowing a role for non-physicians. BMJ. 2003;326(7383):271-273. [Context Link]


19. Canadian Nurses Association. National Nursing Framework on Medical Assistance in Dying in Canada. Ottawa, ON, Canada: Canadian Nurses Association; 2017:1-50. [Context Link]


20. Elmore J, Wright DK, Paradis M. Nurses' moral experiences of assisted death: a meta-analysis of qualitatiave research. Nurs Ethics. 2016:1-18. [Context Link]


21. Francke AL, Albers G, Bilsen J, de Veer AJ, Onwuteaka-Philipsen BD. Nursing staff and euthanasia in the Netherlands. A nation-wide survey on attitudes and involvement in decision making and the performance of euthanasia. Patient Educ Couns. 2016;99(5):783-789. [Context Link]


22. Colquhoun HL, Levac D, O'Brien KK, et al. Scoping reviews: time for clarity in definition, methods and reporting. J Clin Epidemiol. 2014;67:1291-1294. [Context Link]


23. Arksky H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19-32. [Context Link]


24. Voorhees JR, Rietjens JA, van der Heide A, Drickamer MA. Discussing physician-assisted dying: physicians' experiences in the United States and the Netherlands. Gerontologist. 2014;54(5):808-817. [Context Link]


25. Pasman HR, Willems DL, Onwuteaka-Philipsen BD. What happens after a request for euthanasia is refused? Qualitative interviews with patients, relatives and physicians. Patient Educ Couns. 2013;92(3):313-318. [Context Link]


26. Dees MK, Vernooij-Dassen MJ, Dekkers WJ, Elwyn G, Vissers KC, van Weel C. Perspectives of decision-making in requests for euthanasia: a qualitative research among patients, relatives and treating physicians in the Netherlands. Palliat Med. 2013;27(1):27-37. [Context Link]


27. Booij SJ, Engberts DP, Rodig V, Tibben A, Roos RA. A plea for end-of-life discussions with patients suffering from Huntington's disease: the role of the physician. J Med Ethics. 2013;39(10):621-624. [Context Link]


28. Dieltjens SM, Heynderickx PC, Dees MK, Vissers KC. Linguistic analysis of face-to-face interviews with patients with an explicit request for euthanasia, their closest relatives, and their attending physicians: the use of modal verbs in Dutch. Pain Pract. 2014;14(4):324-331. [Context Link]


29. Wright DK, Chirchikova M, Daniel V, Bitzas V, Elmore J, Fortin M-L. Engaging with patients who desire death: interpretation, presence, and constraint. Can Oncol Nurs J. 2017;27(1):56-73. [Context Link]


30. Jannette J, DeWolf Bosek MS, Rambur B. Advanced practice registered nurse intended actions toward patient-directed dying. JONAS Healthc Law Ethics Regul. 2013;15(2):80-88; quiz 89-90. [Context Link]


31. Smith KA, Harvath TA, Goy ER, Ganzini L. Predictors of pursuit of physician-assisted death. J Pain Symptom Manage. 2015;49(3):555-561. [Context Link]


32. Snijdewind MC, van Tol DG, Onwuteaka-Philipsen BD, Willems DL. Complexities in euthanasia or physician-assisted suicide as perceived by Dutch physicians and patients' relatives. J Pain Symptom Manage. 2014;48(6):1125-1134. [Context Link]


33. Brinkman-Stoppelenburg A, Vergouwe Y, van der Heide A, Onwuteaka-Philipsen BD. Obligatory consultation of an independent physician on euthanasia requests in the Netherlands: what influences the SCEN physicians judgment of the legal requirements of due care? Health Policy. 2014;115(1):75-81. [Context Link]


34. Meeussen K, van den Block L, Bossuyt N, Echteld M, Bilsen J, Deliens L. Dealing with requests for euthanasia: interview study among general practitioners in Belgium. J Pain Symptom Manage. 2011;41(6):1060-1072. [Context Link]


35. Ten Cate K, van Tol DG, van de Vathorst S. Considerations on requests for euthanasia or assisted suicide; a qualitative study with Dutch general practitioners. Fam Pract. 2017;34(6):723-729. [Context Link]


36. Otte IC, Jung C, Elger B, Bally K. "We need to talk!" Barriers to GPs' communication about the option of physician-assisted suicide and their ethical implications: results from a qualitative study. Med Health Care Philos. 2017;20(2):249-256. [Context Link]


37. De Hert M, van Bos L, Sweers K, Wampers M, de Lepeleire J, Correll CU. Attitudes of psychiatric nurses about the request for euthanasia on the basis of unbearable mental suffering (UMS). PLoS One. 2015;10(12):e0144749. [Context Link]


38. Castelli Dransart DA, Scozzari E, Voelin S. Stances on assisted suicide by health and social care professionals working with older persons in Switzerland. Ethics Behav. 2017;27(7):599-614. [Context Link]


39. Marcoux I, Boivin A, Arsenault C, Toupin M, Youssef J. Health care professionals' comprehension of the legal status of end-of-life practices in Quebec: study of clinical scenarios. Can Fam Physician. 2015;61(4):e196-e203. [Context Link]


40. Feldt KS, Bond GE, Jacobson D, Clymin J. Washington State Death with Dignity Act: implications for long-term care. J Gerontol Nurs. 2011;37(10):32-40. [Context Link]


41. De Oliveira MLC, de Oliveira Cavalcanti E, Alves VP, da Silva AC. Euthanasia from the perspective of nursing undergraduate students: concepts and challenges. Rev Min Enferm. 2014;18(1):134-141. [Context Link]


42. Pavlish C, Brown-Saltzman K, So L, Heers A, Iorillo N. Avenues of action in ethically complex situations: a critical incident study. J Nurs Adm. 2015;45(6):311-318. [Context Link]


43. Lemiengre J, Dierckx de Casterle B, Schotsmans P, Gastmans C. Written institutional ethics policies on euthanasia: an empirical-based organizational-ethical framework. Med Health Care Philos. 2014;17(2):215-228. [Context Link]