Table 2 Summary of themes and associated practice suggestions

 Encourage MAID awareness

• Hospitals and clinics which care for patients at high risk of death should have publicly available information about MAID so patients are aware of this option

• Awareness efforts should target the general public and families to help prepare them for the possibility their loved ones may choose MAID

• Institutions should have clear policies around HCPs bringing up MAID

 Explore requests for MAID

• HCPs should be aware that patients may struggle to bring up MAID, even if they are seriously considering it

• Support HCPs in how to recognize and explore requests for a hastened death

• Use direct language to acknowledge and explore a patient’s request for MAID

 Facilitate written requests

• Written requests and other paperwork need to be simple and accessible

• Assist with completing the written requests and witnessing, to avoid the need for corrections/revisions, and consequent delays in care

• Provide contact information for Dying with Dignity which can provide volunteer witnesses, or have institutional volunteers who can assist inpatients

 Move MAID requests forward quickly

• Have clear institutional policy/protocol for referring patients who request MAID

• Policies should be supportive of conscientious objectors but mandate rapid referral/transfer of patients so as not impede timely response to MAID requests

• Provide a map MAID process to patients so they can keep track of next steps and hold the team accountable for moving the request forward

 Assess in a safe, comfortable space

• Provide an outline of the purpose and content of the assessment

• Identify private spaces for assessments, ask the patient where they would like to meet and who they would like to have present

• Consider use of videoconferencing/telemedicine, as traveling for an assessment may be a challenge for some patients

 Assessors need to build trust

• Introduce clinicians and their role in the MAID process

• Acknowledge the need to build trust, if this is a new relationship

• Frame the assessment as a conversation; explain the legal criteria for MAID

• Use a conversational manner rather than “checklist” approach to encourage information sharing

• Facilitate involvement of clinicians the patient has an existing relationships with (eg. family physician) in the assessment process

 Provide transparent procedural safeguards

• Reinforce that the patient can change their mind or stop the process at any time

• Having a portion of the assessment with and without family present to ensure non-coercion; be transparent about the reasons for this

• Having two HCPs present for each assessment (eg MD/NP with an allied health member) can be a safeguard for both the patient and HCP

 Provide education

• If the patient is willing, encourage close family members to be present during the assessment, so they can understand the patient’s motivations for MAID

• Use the assessment as an opportunity to educate and prepare patients and families; MAID assessors and providers often have the best information on what to expect and prepare for

 Getting affairs in order

• Develop a list of tasks to be completed, including estate planning

• Involve social workers to assist in these decisions and processes as some families may find making arrangements cathartic while for others is may be burdensome

 Support patient and family reflection

• Prepare patients and families for the emotional nature of the waiting period and acknowledging that complexity of emotions they may be experiencing

• Ask and explore what families and patients need to make the most out of the waiting period

• Specialist palliative care consultation can provide valuable support

 Monitor patient status

• Identify patients at risk of losing capacity early, and ask patients/families if this is a source of anxiety for them

• Explain available options and assess preferences in the event that capacity is lost

• For patients at high risk of losing capacity, consider close monitoring or expediting assessments and consent process

• Offer to reassess patients who have lost capacity as this may fluctuate

• Discuss with patients palliative care options which may best preserve capacity, if MAID is their overriding preference

 Incorporate patients’ spiritual and cultural death practices

• Explore preferences for spiritual/religious counselling is important regardless of stated religious followings

• It may be helpful to identify faith leaders from various religions who are supportive of MAID and can “step in” to the role of the patient/family’s usual faith community

• Non-religious patients may have other rituals or practices

 Offer organ donation, if potentially eligible

• Use standardized screening process for donation so no more patients are approached than necessary, but all potentially eligible patients are asked

• MAID assessor/providers may not be knowledgeable about donation; education may be required

• Organ donation organizations should develop toolkits and standard practices to assist MAID assessors, providers, and patients with these discussions

 Support patient choices for location, route, and timing of death

• Provide clear information about feasible options regarding where, when, and how the MAID provision will occur

• Provide the option of oral MAID provision to have further control only if available and feasible and provider is comfortable providing it

• Explore with patients who they wish to have present during the provision; it may differ from family preferences

 Choreograph the assisted death

• Accommodate patient and family requests when feasible, but be honest when some options cannot be done

• Take exceptional care to be on time or early as delays in provision are very distressing to some patients and families

• Care coordination between locations needs to be planned thoroughly and in advanced to ensure a smooth, confident provision process

• Patients having control over their death is important to them

• Dignity and independence through control brought by on MAID

 Prepare the family for the patient’s death and follow-up

• Tailor education to the needs and understanding of the patient and family

• Ask how much detail families want to know; some value specific information on syringes, colour change, time until heart stops while others may not

• Support and brief the family before and after provision

• Have a space for patients to gather afterwards without being rushed

 Provide continuity of care

• Ask the patient which clinicians they would like involved in MAID

• Engage the primary clinical team in the MAID process, including family physicians (if patient is in hospital) and sub specialists, irrespective of the patient’s location

• Identify a “most responsible MAID clinician” or MAID coordinator

 Provide education and manage expectations

• Provide multiple opportunities and methods for education, written and verbal

• Check for understanding

• Ensure that patient and family expectations are clear with respect to eligibility criteria, what assisted dying entails, and how flexible clinicians can be in providing assessments, assisting with preparation for death, provision, and aftercare

 Facilitate access

• Patients may require advocacy from clinicians to overcome barriers to access

• Check-in on tasks and next steps to ensure the process continues to move along

 Explore previous experiences with death and dying

• Probe for previous experienced with death and dying during assessments to help predict a patient and/or family’s needs throughout the process

 Preserve dignity and privacy

• Provide compassionate care aimed at maintaining an individual’s dignity— what this means will vary between patients and families

• Exercise even more than usual caution in keeping MAID information confidential than other personal health information

 Be sensitive to stigma

• Be aware that patients and families may have experienced stigma and may take time to trust even well-meaning clinicians

• Anticipate that patients and families will struggle with whom to share information about MAID request and how/when to disclose; support patients to tell their families and friends

• HCPs should explore with patients and their family members how they are going to tell and how they are going and offer support for those conversations

 Care for the whole family

• Engage families early and if not involved, explore the reasons why with the patient

• Anticipate the complexity of emotions that family members will experience supporting their loved one’s decision for a hastened death

• Bereavement and follow-up services should be provided to families, where available