Registed Nurses' Association of Ontario

Draft Guidance on Nurses’ Roles in Medical Assistance in Dying (College of Nurses of Ontario)

Draft Guidance on Nurses’ Roles in Medical Assistance in Dying (College of Nurses of Ontario)

On behalf of the Registered Nurses’ Association of Ontario (RNAO), the professional association representing registered nurses (RN), nurse practitioners (NP) and nursing students in Ontario, we thank the College of Nurses of Ontario (CNO) for the opportunity to review the draft guidance on nurses’ roles in offering medical assistance in dying. Given the timelines and pressing deadlines, RNAO has conducted a rapid review of the document and this review could be complemented by additional dialogue with the CNO. In the meantime, the draft document is a step in the right direction during a fluid situation at the federal/provincial levels.

We offer the following recommendations:

  1. Lines 31-32: To convey the significance of complying with legal requirements, it would be beneficial to notify nurses that when they knowingly fail to comply with legal requirements, they may be convicted of a criminal offence and/or face civil litigation and/or face professional/employment discipline.
  2. Lines 37-39: RNAO fully supports the right of nurses to consciously object to participating in and/or providing medical assistance in dying. However, we urge the CNO to strengthen its requirements and wording regarding the duty to refer. We ask that the current wording of "should" on line 37: “Nurses who consciously object should refer or transfer a client who has made the request for medical assistance in dying to another health care provider” be replaced with either "must" or "have a duty to." We also urge CNO to require nurses to make an effective referral. The College of Physicians and Surgeons defines an effective referral as: “… a referral made in good faith, to a non-objecting, available, and accessible [provider] or agency” (CPSO, 2016). Doing so will minimize disruption and facilitate access for patients pursuing medical assistance in dying as a legally recognized health service.
  3. Lines 47-50: When describing RNs’ role in assisting an NP and/or physician, the College does not currently include that it could be an RN who facilitates a patients’ referral to an NP and/or physician to initiate the process (should the patient request this service). For many people, an RN could be their most frequent, or only, contact with a health professional.
  4. Lines 52-54: RNAO disagrees with CNO’s decision to forbid RNs from administering medication. Federal Bill C-14 would permit RNs to “… do anything for the purpose of aiding a medical practitioner or nurse practitioner to provide a person with medical assistance in dying.” (s. 241(3)). Thus, RNAO recommends that CNO authorize RNs to administer medication under the direction of an NP or physician.
  5. Lines 56-59: Despite being prohibited from administering medications to deliver voluntary euthanasia, RNs would be permitted to assist clients with the self-administration of medication that has been prescribed by an NP or physician. Depending upon the degree of physical disability, the extent of aid provided by an RN could border on active involvement. Therefore, it is unclear why CNO is permitting RNs to aid patients with self-administration, however, not deliver prescribed medications with voluntary euthanasia? Moreover, little guidance is offered to RNs who will assist patients with self-administration. For example, what safeguards must they follow?
  6. Missing from the document is guidance surrounding nurses’ obligations to advise patients about end-of-life care options. RNAO believes that patients should be made aware of all of their end-of-life care options, including medical assistance in dying. To support the delivery of quality and safe end-of-life care, we request that CNO reference RNAO’s evidence-based guideline: End-of-Life Care During the Last Days and Hours. This guideline was developed by an expert panel and informed by a systematic review of the literature and robust stakeholder engagement.
  7. Lines 117-126: The draft document is missing guidance around situations where a nurse disagrees with a finding of capacity and/or incapacity. This omission represents a substantive gap that, in the view of RNAO, must be corrected.
  8. Lines 174-176: The document specifies that the minimum waiting period can be shortened if it is the NP’s opinion that the client’s death, or loss of capacity is imminent. It would be helpful to provide more guidance around the definition of “imminent”.
  9. Lines 180-190: The draft document identifies that NPs are not authorized to prescribe controlled substances. This significantly limits the ability of NPs to deliver person-centred care, including providing medical assistance in dying. RNAO urges the college, in the strongest possible terms, to promptly pursue regulatory amendments that would permit NPs to prescribe all controlled substances. This is not only important in delivering medical assistance in dying, but also for other end-of-life care options, supporting trans-persons, delivering harm reduction programs and providing effective pain management. In June 2014, RNAO reviewed a revised NP practice standard from CNO that included the authority of NPs to prescribe controlled substances (RNAO, 2014). However, regretfully and with strong concerns, RNAO has seen no progress since that time. As the CNO is fully aware, Ontario lags behind other Canadian jurisdictions and most American states, in authorizing NPs to deliver controlled substances. The time for decisive action is now!
  10. Lines 205-208: NPs are specified as being able to certify a client’s death. At RNAO’s Annual General Meeting on May 5 2016, Minister of Health and Long-Term Care Dr. Eric Hoskins announced that the government is pursuing regulatory changes to authorize RNs to sign medical certificates of death. RNAO urges the college to promptly support and enable these regulatory changes.

Anne, thank you for the opportunity to review the draft document. RNAO commends CNO for being proactive and for engaging with stakeholders to craft this document. We urge you to please implement our feedback.

Warm regards,

Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT.
Chief Executive Officer
Registered Nurses' Association of Ontario

See the full letter with references below

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