Medical Assistance in Dying (MAiD) became legally accessible to Canadians in 2016, bringing with it significant changes to the Canadian health care landscape. With legalization of MAiD, physicians, nurses and allied health care workers had to consider their own systems of values, beliefs and their professional identity and decide whether or not they would be able to contribute to this practice or participate actively in this new medical procedure. I argue that health care professionals who participate in this practice create a professional identity that is intrinsically bound to the ethics and practice of MAiD, thus making it permissible for them to support and participate in the procedure actively. Moreover, I argue that this system of morals and beliefs has been accrued by these health care professionals across experiences and time that contribute to their capacity to participate in MAiD. Hamilton Health Sciences (HHS) was the locus for this research. HHS encompasses a network of five hospitals in the Hamilton, Ontario area. Each hospital region in Ontario has a unique staff and values, and HHS is no exception. HHS houses the Assisted Dying Resource and Assessment Service (ADRAS) group, a team of uniquely skilled MAiD providers, assessors and health professionals who service the HHS patient community. It is this group that is at the center of this research. Through interviews with members of ADRAS, I determined that values of altruism, belief in self-determination and deep respect for patients and families are central to the individual and collective identities of this group. In light of this ethical stance, members of ADRAS have crafted complex professional identities both individually and as a collective that enable them to participate in MAiD in a complete and meaningful way. / Thesis / Master of Arts (MA)

No / The clinical and social epidemiology of living with a life-threatening or life-limiting illness, frail ageing, long-term caregiving, and grief and bereavement is well documented in the palliative care, psycho-oncology and psychiatric literature but this investigation asks what interest exists from the mainstream public health sector in these health and illness experiences. This paper reports a content analysis of 7 key British public health journals, 14 major public health textbooks and 3 public health websites employing key word and synonym searches to assess the size and quality of interest in populations related to ageing, dying, caregiving, and grief and bereavement. Compared with other public health issues, such as obesity and tobacco use, for examples, interest in the social experience and epidemiology of end-of-life experiences is extremely low. Reasons for this lack of interest are explored.

- / This article makes critical observations about the popular examination of dying and its care, identifies the key challenges to modern dying, and argues for a public health approach to end-of life care. Only by adopting a global and non-clinical perspective on the human experience of dying can we address people’s concerns where these arise—in their own homes and workplaces—and to offer alternatives to the more radical choices offered by modern medicine.

Allt fler människor i samhället dör på sjukhus. Detta gör att sjuksköterskan får ett större ansvarsområde i sin yrkesfunktion i relation till patientens döendeprocess. När patienten kommer till insikt om att livet är på väg att ta slut aktiveras en av de mest grundläggande försvarsmekanismer som människan har, ångest. För att sjuksköterskan skall kunna stödja patienten i upplevelsen av oro och ångest i döendeprocessen är det av betydelse att öka kunskapen inom omvårdnadsvetenskapen. Därför var syftet med denna litteraturstudie att beskriva patienters upplevelse av oro och ångest i döendeprocessen. I litteraturstudien granskades 11 vetenskapliga artiklar. I resultatet framkom 5 teman: ångest en del av döden, behovet av att få diskutera sin upplevelse av ångest, faktorer som påverkar patientens upplevda oro och ångest, patientens ångest relaterat till vårdteamet och familjen och att acceptera döden i relation till oro och ångest. Ångest är något naturligt för patienten att uppleva i döendeprocessen. Ångesten håller tillbaks patienten och gör att patienten får möjlighet att sammanfatta sitt levda liv vilket i slutändan gör att patienten kan acceptera döden. Det finns många faktorer som påverkar, framkallar och förstärker den ångesten patienten upplever. Detta kan vara alltifrån en förändring i omvårdnadsrutiner till ett symtom som inte går att kontrollera. Det finns även en positiv sida av ångest då de relationer patienten har till människor i sin omgivning kan förstärkas. Sjukvården ser patienten och närstående som en enhet vilket medförde att patienten kände sig tvingad att dela med sig av informationen till närstående, vilket förstärkte patientens ångest. Det behövs mer forskning för att öka kunskapen hos hälso- och sjukvårdspersonal om patienters upplevelser av ångest i döendeprocessen. / An increasing number of persons from the society die in hospitals rather than at home. This allows the nurse to gain a greater responsibility in their professional function in relation to the patients’ process of dying. When the patient realizes that life has reached its end, anxiety is perceived which is a natural defense mechanism of humans. To provide a basis for nurses to support the patient in this experience of anxiety, it is essential to improve the knowledge of the dying process in nursing science. The purpose of this literature study was therefore to describe patients’ experience of anxiety during the process of dying. In this study, 11 scientific articles was scrutinized and used as a basis for the result. This revealed five classes of studies: anxiety as a part of death, patients need for discussing their experience of anxiety, elements that affect the patients experienced anxiety, the patients anxiety related to the care team and the family and the acceptance of death related to anxiety. Anxiety is a natural part of the dying process. The anxiety slows down the patient, who is then able to summarize its life and to finally accept death. Many elements affects, provoke and amplifies the experienced anxiety for example changed routines or untreatable symptoms. There are also beneficial effects of anxiety since relations that the patient have with its relatives may be strengthened. However, healthcare currently consider the patient and its relatives as a unit, which may force patients to share information about their health status which may lead to an amplified sense of anxiety. More research is essential in order to enhance the knowledge among healthcare personnel of patients’ experience of anxiety in the process of dying.

In oncology setting, there is a range of emotions felt by patients and nurses alike such as helplessness, anger, sadness and anxiety; and this is especially the case as patients near the end of life. The literature shows there is an interest in nurses' attitudes toward caring for patients who are near the end of life. This project examines the overall attitude of Bone Marrow Transplant (BMT) nurses' attitudes toward caring for patients who are near the end of life using the Frommelt Attitudes Toward Care of the Dying Scale (FATCOD) and a Demographic Data Sheet. This project investigated the demographic variables including age, gender, ethnicity, religion, Oncology Certified Nurses status, highest degree held, years of nursing experience, years of oncology experience, years of BMT experience, prior continuing education in end of life, and prior experience taking care of a terminally ill patient, to see if they contribute to these differences in attitudes. This was a descriptive project. The sample consisted of a total of 30 BMT nurses, which included 8 men, and 22 women who have worked on the BMT unit for over a year. The mean years of nursing experience was 13.9 (SD=10.10), mean years of oncology nursing experience was 8 (SD=5.80), and mean years of BMT experience was 7.2 (SD=.60). The results of this project indicate that there is a positive relationship between number of years of experience as a nurse and positive attitudes toward caring for patients who are near the end of life. Scores on the FATCOD had a possibility to range from 30-150, with higher scores indicating a more positive attitude toward care of the dying. The scores from this project ranged from 113-148 with a mean of 128.6, indicating an overall positive attitude toward caring for the dying. This project should spur further investigation into attitudes toward caring for patients who are near the end of life. Nurses strive to take the best possible care of their patients and having an understanding of their attitudes will help them recognize areas of strength and weakness. This project supports interventions that are already being done by End of Life (EOL) Committee on the BMT unit at the Moffitt Cancer Center. The EOL committee is helping to create positive attitudes about caring for patients who are near the end of life by both supportive and educational methods.

This study examined death and dying in assisted living (AL) and the various factors that influence these processes. The study is set in a 60-bed assisted living facility outside of Atlanta, Georgia. Data collection methods included participant observation and in-depth interviews with 28 residents and 6 staff. Data were analyzed using the grounded theory approach and focused on the 18 residents who were dying and/or died during the study period. Findings show that AL residents experience a variety of dying trajectories that vary in duration and shape; for the majority of residents, hospice is an important element in their death and dying experiences. In general, death is not communicated or acknowledged formally within the facility. Responses to deaths depend largely on the nature of the relationship the deceased resident had with others. Findings have implications for how to handle death and dying in AL and to improve residents‟ experiences.

This inquiry, which employed a narrative research approach, critically explored the ethical dimension of hospice palliative care. Hospice palliative care is the profession specifically developed to care for the dying. The development of this practice has grown significantly since the 1980s in Australia, yet ethical inquiry into this professional practice has largely focused on particular issues, problems or dilemmas, such as euthanasia. Although particular ethical issues are important considerations, a broader investigation of the ethics of hospice palliative care practice has not been given sufficient consideration in the growing accumulation of the research literature in Australia. Jennings (1997) surmises that “systematic reflection on ethics in the hospice field is curiously underdeveloped” (p. 2). This study goes someway towards filling this gap. In building upon the Pallium research by European scholars and integrating a social practice framework (Isaacs, 1998) this inquiry provides an alternative account of the ethical agenda and one which has privileged an internal exploration, rather than assume that the ethics would be the same as any other health care modality or to simply adopt a dominant, principles-based approach. These internal explorations were located in the storied accounts of thirty interdisciplinary hospice palliative care professionals. This thesis provides a thorough, textual conversation into the realm of ethical caregiving at the end of life. Several key insights were illuminated. Firstly, total care must be central to the philosophy underpinning hospice palliative care practice, but this concept and practice of total care was being eroded and contested. Secondly, a predominantly modernist account of personhood was located in the narrative accounts. This modernist account of personhood was thought to be insufficient for the practice of total care and needed to be reconceptualised. An embedded ontological account was provided which would assist with the understanding and practice of total care. Thirdly, initially it was thought that there was no common, shared understanding of the purpose of the practice. It was suggested that the profession was “wandering in the wilderness” when it came to the aim of its practice. However, the professionals did share a common telos (aim towards a good) and it was overwhelmingly relational. This led to the proposal of a new telos for hospice palliative care practice centered on the creation and maintenance of unique relationships which would assist people in their final stage of life. Lastly, the ethical frameworks which guided practice for the professionals were presented. In these frameworks it was significant values (acceptance of human mortality, total care and honest and open communication) and relationships (how we treat each other) which played the main role in what constituted hospice palliative care ethics. An account of a hospice palliative care ethical relationship was provided which included a proximity stance of in-between. Overall, any ethic for hospice palliative care must have at the heart the relationship between professional caregiver and living-dying person. The relationships in this social practice, between each other, accompanying one another, are our ethical compass. This thesis concluded that hospice palliative care, as a social practice, has a rich ethical dimension as understood and articulated by its professional members. These insights have resulted in the construction of a new ethical framework reflecting, formalising and adapting the ethical dimension as understood by its professional members. This ethical framework - A Relational Ethic of Accompanying - is needed to help maintain, sustain and protect the unique identity of this profession. This framework adds to the “moral vocabulary” (Jennings, 1997) and “moral specificity” (ten Have & Clark, 2002) of hospice palliative care practice. In addition, it would provide important guidance to palliateurs reflecting on how best to provide quality, compassionate and ethical care at the end of life.

The thesis focuses on the possibilities to use elements of palliative hospice care in the retirement home. The work describes basic theoretical themes such as human dignity, its interpretation and dignified dying. It also presents basic issues concerning dying and death, ethical problems of different phases of dying, as well as the dying person's needs. The thesis tries to answer the question about the possibility of dignified dying through the use of hospice care. It also defines palliative care provided in hospices as one of the approaches to long-term care of dying people. The research analyses two standards of nursing care in retirement homes The care of a dying person and The care of a dead person. It presents results of its own research method realized through semi-structured interviews with clients of a retirement home. The aim of the research is to find out whether the clients themselves are interested in application of hospice palliative care in the retirement home.

V disertační práci se věnuji etickým problémům, se kterými se setkávají zdravotníci při péči o umírající nemocné. první kapitole přibližuji problematiku péče o umírající pacienty, předkládám pohled do historie péče o umírající a zaměřuji se na klíčová kriteria při péči o umírající, kterými jsou potřeby nemocných. druhé kapitole popisuji metodologickou část kvalitativního výzkumu, kterého se zúčastnilo 15 sester ze standardních oddělení, jednotky intenzivní péče a anesteziologicko resuscitačního oddělení Nemocnice Na Bulovce. Cílem výzkumného šetření bylo, prostřednictvím rozhovorů se sestrami, vyhledat a popsat etické problémy, se kterými se setkávají sestry při péči o umírající kontextu tří různých prostředí a v konkrétních situací Ve třetí kapitole uvádím komentované výsledky rozhovorů, ze kterých vyplynulo, že se sestry zamýšlejí nad ochranou lidského života v jeho kvalitou, dystanázií, marnou léčbou, rozdílem mezi ponecháním pacienta zemřít a eutanázií, autonomií, lidskou důstojností a poskytováním paliativní péče. Jednotlivé podkapitoly se skládají z teoretického zarámování a jsou doplněny o výpovědi respondentek výzkumného šetření a rozšířeny o můj komentář. Hlavním zjištěním je, že dotazované sestry trpí tzv. morálním distresem, který ovšem prezentují především v sérii konkrétních výhrad...

V disertační práci se věnuji etickým problémům, se kterými se setkávají zdravotníci při péči o umírající nemocné. první kapitole přibližuji problematiku péče o umírající pacienty, předkládám pohled do historie péče o umírající a zaměřuji se na klíčová kriteria při péči o umírající, kterými jsou potřeby nemocných. druhé kapitole popisuji metodologickou část kvalitativního výzkumu, kterého se zúčastnilo 15 sester ze standardních oddělení, jednotky intenzivní péče a anesteziologicko resuscitačního oddělení Nemocnice Na Bulovce. Cílem výzkumného šetření bylo, prostřednictvím rozhovorů se sestrami, vyhledat a popsat etické problémy, se kterými se setkávají sestry při péči o umírající kontextu tří různých prostředí a v konkrétních situací Ve třetí kapitole uvádím komentované výsledky rozhovorů, ze kterých vyplynulo, že se sestry zamýšlejí nad ochranou lidského života v jeho kvalitou, dystanázií, marnou léčbou, rozdílem mezi ponecháním pacienta zemřít a eutanázií, autonomií, lidskou důstojností a poskytováním paliativní péče. Jednotlivé podkapitoly se skládají z teoretického zarámování a jsou doplněny o výpovědi respondentek výzkumného šetření a rozšířeny o můj komentář. Hlavním zjištěním je, že dotazované sestry trpí tzv. morálním distresem, který ovšem prezentují především v sérii konkrétních výhrad...