Course:SOWK551/2021/A Review of the Social Work Role in the Process of MAiD within Healthcare
Literature review of the social work role in the process of MAiD within healthcare.
Medical Assistance in Dying (MAiD) has been evolving at a rapid rate in Canada over the last 6 years and when we reflect upon the future of this legislation, there appears to be no slowing down in sight. Medical Assistance in Dying occurs when a medication is intentionally administered by a doctor or nurse practitioner that at the request of an individual, brings about their death (Government of British Columbia, 2022). The federal government of Canada passed legislation to amend the criminal code and introduced MAiD into practice on June 17th, 2016 under Bill C-7. Five years later, the original legislation was modified and on March 17th, 2021 Bill C-14 was implemented (Government of British Columbia, 2022). The major change to eligibility criteria between Bill C-7 and Bill C-14 is that a “two track system was created”, one for folks with a naturally foreseeable death and one for those with a “grievous and irremediable condition” but whose natural death may not be reasonably foreseeable (Pesut et al., 2021). The objective of MAiD legislation is to provide an end-of-life care option that respects a patient’s autonomy while subsequently relieving their suffering (Sulmasy et al., 2017). Discussions surrounding MAiD are important to the healthcare profession because it has had a major effect on both the conversations and outcomes of patients seeking end-of-life and palliative care.
At the end of 2020, the number of individuals receiving MAiD had grown by 34.2% from 2019 and MAiD accounted for 2.5% of all deaths in Canada totalling 21,589 people receiving it in the year (Pesut et al., 2021). As MAiD legislation becomes more relevant in the day to day lives of Canadians, it also becomes increasingly prevalent within healthcare and subsequently in the role and involvement of the interprofessional healthcare team. Because of this, this paper aims to provide an analytical review of the social work role in the process of MAiD within healthcare. In doing this, this paper will synthesize the literature to provide a review of the role of social work in death and dying, the legal and ethical considerations related to MAiD, and the relevance of the social determinants of health. Additionally, an analysis of how this literature review might be applied to social work practice in healthcare will be discussed.
This literature review consists of 17 scholarly articles published between 2005 to 2022. The peer-reviewed articles were found using google scholar and the UBC library search engine. To gather the most relevant articles about my literature review, the following keywords were used: “MAiD within Canada”, “legal and ethical considerations” “social work”, “healthcare”, and “social determinants of health”. These keywords were used both alone and in various combinations. The findings were examined from a Canadian context and therefore focus on the Canadian legislation and experiences of Canadian healthcare providers. Upon analysis of the latest literature, the following three themes were identified: (1) Social Work Practice in Death and Dying, (2) Legal and Ethical Obligations related to MAiD, and (3) the Relevance of the Social Determinants of Health. The purpose of this literature review is to inform healthcare social workers on how to improve their role in the process of Medical Assistance in Dying.
Social Work Practice in Death and Dying
All social workers will interact with death and dying at some point in their professional journeys. Gwyther et al. (2008) suggests that social workers hold a unique position in which they are notably “qualified and positioned” to provide services in end-of-life care. In agreeance is Hobart (2008) who notes that social workers “have the training and expertise” to identify psychosocial factors related to death and dying that help to effectively speak with the family members of a person who may be nearing or thinking about death. Because of this, social workers are expected to have the necessary knowledge to provide general information about the process of MAiD and liaise with the rest of the team to determine the next steps. Amurao (2020) suggests that when social workers lack an understanding of MAiD, they may experience higher levels of work-related stress and personal anxiety. It can be concluded that having a high level of confidence for social workers in the process of MAiD will not only benefit the patient and the interdisciplinary team, but it will also influence how social workers feels about the rest of their practice.
Christ and Sormanti (2008) share findings from their study that argue social workers feel as though graduate-level studies do not provide a substantial level of understanding on how to work with patients who are dying or grieving. It was shown that only 54% of social workers rated their interventions related to death and dying with patients and families as “good” or “excellent”. In addition, research conducted by Alkema, Linton, and Davies (2008) notes that social workers often face multifaceted challenges when working with death and dying such as their personal grief and the grief of patients. Similarly, a study conducted on “vague end-of-life policies” showed social workers often feel unprepared for ethical considerations that arise amidst end-of-life care (Amurao, 2020). To prevent this, Westefeld (2013) argues that human service workers should be provided with additional training on how to work with patients and families who are requesting MAiD. However, Gaston (2018) states that knowledge about the factors that influence a social worker’s preparedness in end-of-life care has yet to be studied in much of the available literature. Regardless of literature support, the role of social work in death and dying and subsequently the involvement with patients and families in the process of MAiD can be both rewarding and difficult, however many times it will be both.
The Medical Assistance in Dying legislation has been under ethical and legal critique since it was first introduced in 2016 and the rapid expansion to MAiD has resulted in a noteworthy debate within palliative care settings (Pesut et al., 2021). Some Canadians view MAiD as a “commendable act of compassion, while others consider it an act of severe violence”. The most prevalent argument used in favour of MAiD is a person’s right to autonomy. Within a western culture and medical ethics, autonomy is looked at as one of the most fundamental principles of healthcare, and the impact of autonomy is one of the key arguments in favour of MAiD (Allan & Allan., 2020; Westefeld et al., 2013). The social work profession is rooted in a framework of social justice whereby fairness, equality, and respect for all people is at the forefront of the practice. As a result of this framework, social workers advocate for people’s rights to self-determination and their ability to make informed and voluntary decisions (CASW, 2022). Interestingly, Wright and Shaw (2019) discuss that in medical decisions, a patient’s autonomy is normally used to allow folks the right to refuse treatment options rather than to allow requests for specific treatment options.
The legislation of MAiD may affect social workers at all levels of practice however, due to its medical nature, social workers within healthcare are often the ones that encounter it most frequently. As per Amurao (2020), social workers are part of the interdisciplinary team and therefore abide by the ethics and values that guide holistic and person-centered care. As Gaston (2018) states, social workers working in end-of-life care are expected to become experts in both the bioethical issues and legal considerations of MAiD. Using biopsychosocial assessments to determine a person’s needs, social workers may be the first person to hear of a patient expressing their desire for MAiD (Amurao, 2020). Although the criminal code exempts criminal prosecution for healthcare providers involved in the provision of information for MAiD, as per the Newfoundland and Labrador Association of Social Workers (2016), “it remains a criminal offence to counsel a person to die by suicide as outlined in the Criminal Code, subsection 241(1)”. Concerns about initiating MAiD conversations remain an ethical consideration for many healthcare providers out of fear of accidentally influencing a patient’s decision, sending the wrong message, or negatively impacting a working relationship (Ho et al., 2021). On the other hand, some medical professionals have argued that many patients react positively when healthcare workers initiate end-of-life conversations (Hot et al., 2021). Due to the complex ethical and legal considerations that are ongoing with MAiD legislation, social workers should maintain their competence through ongoing education of polices and issues related to end-of-life care and MAiD.
The Social Determinants of Health
As the MAiD legislation continues to develop and the population that accesses it continues to expand, concerns have been raised about what psychosocial factors may drive people to an initial request for MAiD. As members of the interdisciplinary team, social workers are often the first ones to complete biopsychosocial assessments to assess what a patient believes they need for an “optimal quality of life” (Amurao, 2020). It has been researched that the individuals who are choosing MAiD are commonly well-educated and of higher socio-economic status and therefore, are more often able to advocate for themselves to have access to end-of-life care (Downer et al., 2020). In agreeance with this, Westefeld et al. (2013), states that those in favour of medical assistance in dying are primarily “white and able-bodied” individuals. Due to their social determinants of health, these individuals are more likely to have a consistent medical practitioner. The healthcare system in Canada relies upon the relationships between family doctors and patients (Wright & Shaw, 2019). However, as argued by Wright and Shaw (2019), accessing appropriate treatment, and having end of life discussions “present as a unique barrier” for marginalized individuals often due to “inconsistent or non-existent relationships with physicians” (Wright & Shaw, 2019). Marginalized individuals frequently face structural and systemic barriers when interacting with the healthcare system due to “poverty, homelessness, racism, ageism, substance use, and mental health diagnoses” (Wright & Shaw, 2019).
The influence of social determinants on a person’s health is viewed by many scholars as a driving factor behind many MAiD requests in Canada. Many studies have articulated that patient’s often seek MAiD not because of chronic pain or terminal diagnoses but because of poor quality of life and loss of autonomy (Amurao, 2020). Other studies have stated that a lack of self-worth, limited support services, and a reduced social network may influence a patient’s wish for MAiD (Ho et al., 2021). Tran et al. (2021) state that the cost of medical “non-necessities” such as “prescription medications, home care, long-term care, and services offered by nonphysician providers (eg, optometrists, physiotherapists)” can create large health disparities for patients of low economic status. As such, a patient’s request for MAiD may be “a reactive phenomenon intertwined with physical, psychosocial, and existential suffering” related to a broken social safety net rather than a true desire to die (Ho et al., 2021). In agreeance with this understanding is Wiebe et al. (2022), who argues that it is often easier for folks to access MAiD than to get the necessary supportive care that they require to treat their symptoms or psychosocial problems. On the contrary, a study completed by Ho et al. (2021), found that MAiD assessors rarely met with patients where unmet needs and limited resources were the main factors contributing to their request for MAiD. However, findings from a study completed by Brown et al. (2020), showed that more often, patients were requesting MAiD in Canada due to non-physical symptoms such as “quality of life, and desire for dignity and control over death” rather than “physical symptoms like dyspnea or pain”. A Canadian annual report on MAiD indicated that in 2020, 18.6% of patients noted that feelings of isolation or loneliness were a factor in their suffering (Health Canada, 2021). Based on the findings, there appear to be discrepancies about whether the influence of psychosocial factors such as a person’s housing or income is a true driving factor to access MAiD. However, it can be recognized that non-physical symptoms such as loneliness, and quality of life are pertinent to a person’s final decision about accessing MAiD which are key findings relevant to social work practice.
Application to Practice
MAiD legislation is changing at a rapid rate despite it being relatively new in Canada. This topic is relevant to practice as social workers working in healthcare will more than likely be involved in a care discussion regarding MAiD at some point in their practice and should feel equipped to have difficult conversations with patients and families. By reviewing the social work role in MAiD, the legal and ethical considerations, and the influence of the social determinants of health, this literature review has demonstrated that there is a growing need for healthcare provider competence surrounding MAiD. Due to the sensitive nature and novelty of assisted dying in Canada, there is a lack of literature regarding the topic. Therefore, this paper has provided a literature review to understand how the social work role fits within MAiD in healthcare. This is relevant to practice as it can serve as an educational tool and can guide social workers to a greater understanding of their role.
It can be concluded that the legislation and process of MAiD is a complex issue that continues to elicit difficult discourse between the public and health care providers. As such, this is an important topic for social workers to be aware of, specifically those working within healthcare. Through analyzing the latest research and synthesizing the literature, this paper has discussed key themes relevant to the social work role related to death and dying, the legal and ethical considerations that may arise, and the relevance of the social determinants of health in accessing MAiD. The goal of this research is to highlight important insights regarding the practical challenges experienced in health systems as they continue to develop policies that create best practice for the delivery of MAiD care. The findings from this paper suggest that literature specific to the social work role in the process of MAiD within healthcare is limited and further data should be obtained to better understand why the social work role is important and how it can be modified to best fit the needs of patients and their families.
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