Guidelines for Social Workers on Medical Assistance in Dying

Introduction

MAID means medical assistance in dying and is defined in the Criminal Code as:

  • Voluntary euthanasia – the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes death; or
  • Assisted suicide– the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their own death (Criminal Code, Section 242.1);  (http://www.nshealth.ca/about-us/medical-assistance-dying).

These guidelines provide Nova Scotia social workers with an understanding of social work’s role and responsibilities as it relates to MAID.  The guidelines are based on the College’s Standards of Practice, the Code of Ethics, and the applicable the legal and policy obligations.

Guidelines for Social Workers

Social workers have always been involved with client’s making difficult decisions around their lives.  It therefore follows, that social workers would have a key role in supporting clients as they grapple with the complexities of exploring and requesting Medical Assistance in Dying (MAID).

Social work’s core values and principles; as defined by the CASW Code of Ethics (2008), as amended for the NSCSW, with its standards for practice; as defined in the NSCSW Standards of Practice (2017), lay the foundation for social work practice in Nova Scotia.  In advance of providing social work services in the context of MAID, social workers are strongly encouraged to carefully review these documents in relation to their professional conduct pertaining to MAID.

Social workers are also strongly encouraged to engage in self-care as an important aspect of professional competence.  MAID may invoke strong emotional reactions. Social workers shall engage in critical reflection and seek opportunities to focus on self-care while maintaining professionalism and the respect for the best interest of the client.  Consulting and seeking guidance/support from supervisors/managers and/or seeking input/support from colleagues in a multidisciplinary setting is a helpful strategy.

The College highlights the following regarding social work and MAID:

The Code of Ethics and the Standards of Practice clearly assert that social workers must respect the inherent dignity and individual worth of all persons and uphold a person’s right to self-determination, consistent with the person’s capacity to make informed decisions and to provide informed consent. Bill C-14 provides individuals the legal right to seek medical assistance in dying.  This change in law obligates social workers to support their client’s right to make a choice, based on voluntary, informed consent, in considering or pursuing MAID. As detailed in Value 4 of the Code of Ethics, social workers must strive for impartiality in their professional practice, and refrain from imposing their personal values, views, preferences, stereotypes/assumptions on clients and seek to understand the lived experiences of those whom they serve.  In working to uphold a person’s right to self-determination, social workers will want to strive to ensure clients are free from any coercive factors relating to social or financial circumstances, or due to lack of access to the best possible pain and symptom management.

Code of Ethics

  • Value 1 – Respect for the Inherent Dignity and Worth of Persons
  • Value 2 – Pursuit of Social Justice

Standards of Practice

Social workers with their unique perspectives and areas of expertise are integral members of teams caring for persons considering MAID. Persons seeking MAID are in an extremely vulnerable time in their life. Social workers shall uphold the client’s right to be provided with appropriate social, psychological, and medical resources at this end of life phase. Social workers shall advocate for the fair and equitable distribution of society’s resources to all persons including the right to medical assistance in dying.  Social workers working in MAID shall strive to ensure that their clients are given the opportunity to die in a manner of their choosing and that their clients are supported in their right to choose. Social workers shall advocate for fair and equitable access to MAID and shall bring to light injustices that affect this vulnerable group.

Code of Ethics

  • Value 2 – Pursuit of Social Justice
  • Value 3 – Service to Humanity

Standards of Practice

Social workers shall provide clients with accurate and complete information regarding the extent, nature, and limitations of MAID services available to them and/or ensure clients receive this information in a timely manner. Social workers working in MAID shall work to ensure that they have a solid understanding of the applicable legislation and laws, as well as professional and workplace policies, guidelines, regulations, and standards governing MAID. Social workers shall have a solid understanding of the concepts of capacity and informed consent.  Social workers shall be knowledgeable of and adhere to NSHA policies, guidelines, procedures, and practices and to the current criminal code legislation that guides the delivery of MAID services.  Social workers who have questions and/or concerns around the role of social work in relation to MAID legislation and laws shall seek consultation before engaging with a client in this area.

Social workers shall be mindful of their areas of knowledge and skill and limit their practice to areas of demonstrated competence.  Social workers shall ensure their skills are in keeping with current knowledge and practices in the field of social work.  Members working in MAID shall engage in professional development and training pertaining to social work and MAID.

Code of Ethics

  • Value 4 – Integrity of Professional Practice
  • Value 6 – Competence in Professional Practice

Standards of Practice

Culturally sensitive services, in all contexts, includes practicing with sensitivity and respect for the belief systems and diverse cultural needs of the people within one’s area of practice.  Social workers strive to understand the unique social position(s) of their clients on an individual, family, group, and community level, and to competently apply this knowledge in their service delivery.  Social workers acknowledge that systematic and structural oppressions influence policies and equitable access to programs and services.  Social workers strive to identify and challenge oppressive constructs and systems in advocating for the best interest of the client.

A social worker shall engage in self-reflection and self-assessment to identify any possible impact that their personal values, beliefs, attitudes, behaviours, and practices could have on their practice, and above all on clients whose backgrounds and values differ from their own.

Code of Ethics

  • Value 1 – Respect for the Inherent Dignity and Worth of Persons
  • Value 2 – Pursuit of Social Justice

Standards of Practice

Social workers may be concerned about how their personal values and beliefs will be considered in the provision of MAID. Whilst social workers must respect and uphold a client’s right to make choices based on voluntary, informed consent, the legislation on MAID does recognize and uphold individual’s ‘Freedom of Conscience and Religion’ as outlined in the Canadian Charter of Rights and Freedoms (1982; Section 2(a).  Social workers are not compelled under the MAID legislation to provide or assist in MAID. Social workers do have an ethical responsibility to strive for impartiality in practice and shall refrain from imposing their values, views, and preferences on clients. Social workers opposed to MAID, who believe that their values and beliefs will negatively impact their ability to provide ethical and competent services related to MAID, shall inform their employer and take immediate steps to refer the client and their family to an appropriate social work colleague or qualified health care professional.  Social Workers shall inform a client of the client’s right to consult another professional at any time during the provision of social work services.

Code of Ethics

  • Value 1 – Respect for the Inherent Dignity and Worth of Persons
  • Value 4 – Integrity of Professional Practice

Standards of Practice

Criminal Code of Canada Amendments

In 2016, Bill C-14 of the Federal Government was passed into legislation.  Bill C-14 allows for medical assistance in dying and sets out requirements for the provision of medical assistance in dying in Canada. The Criminal Code of Canada was officially amended to reflect Bill C-14 on June 17, 2016.  With the amendment of the Criminal Code of Canada, specific exemptions for MAID were brought into force, as well as protections for those assisting in this process. The amendment states that “no medical practitioner or nurse practitioner commits culpable homicide if they provide a person with medical assistance in dying in accordance with section 241.2″4” (Criminal Code, Section 241.2(4)).  Additionally, it states that “no person is a party to culpable homicide if they do anything for the purpose of aiding a medical practitioner or nurse practitioner to provide a person with medical assistance in dying in accordance with section 241.2″5”, and that “section 14 does not apply with respect to a person who consents to have death inflicted on them by means of medical assistance in dying…” (Criminal Code, Section 241.2.4; 241.2.5).  It is important to note, that counselling a person to die by suicide or aiding or abetting a person to die by suicide is still an indictable offence (Criminal Code, Section 241.1).

The exemptions laid out in the Criminal Code of Canada are for medical practitioners, nurse practitioners, persons aiding the practitioner or patient, and pharmacists involved in the MAID process.  Social workers, amongst other healthcare professionals, are also offered specific protection, “no social worker, psychologist, psychiatrist, therapist, medical practitioner, nurse practitioner or other healthcare professional commits an offence if they provide information to a person on the lawful provision of medical assistance in dying” (Criminal Code, Sections 241.2, 241.3, 241.4, 241.5).

MAID Eligibility Criteria 

A person may receive MAID only if they meet the following criteria:

  1. they are eligible – or, but for any applicable minimum period of residence or waiting period, would be eligible – for health services funded by a government in Canada;
  2. they are at least 18 years of age and capable of making decisions with respect to their health;
  3. they have a grievous and irremediable medical condition;
  4. they have made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure; and
  5. they give informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care (Criminal Code, Section 241.5.1).

A grievous and irremediable medical condition is defined as a person who meets the following criteria:

  1. they have a serious and incurable illness, disease, or disability;
  2. they are in an advanced state of irreversible decline in capability;
  3. their illness, disease, or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and
  4. their natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining. (http://laws-lois.justice.gc.ca/eng/acts/C-46/page-54.html)

Further safeguards are defined for the medical practitioner or nurse practitioner before providing a patient with MAID. These include:

  1. a written request for MAID must be signed and dated by the patient, after they have been informed they have a grievous and irremediable medical condition, and in front of two independent witnesses;
  2. The patient must also be informed they can withdraw the request for MAID at any time and a second opinion must be provided in writing confirming the patient meets the criteria.(http://laws-lois.justice.gc.ca/eng/acts/C-46/page-54.html)

Nova Scotia Health Authority Policy

The Nova Scotia Health Authority (NSHA) is currently developing a policy around access to MAID for Nova Scotians.  This policy, once released, will govern medical practitioners, including social workers, with regards to MAID.  In the interim, the NSHA has developed a webpage answering FAQ’s (Frequently Asked Questions) on MAID.  If you are a social worker, working within the context of MAID, it is strongly recommended that you stay current on the content of this webpage here.

References and Resources

Canadian Social Work Regulatory Bodies on Medical Assistance in Dying

Questions?

Contact the College’s Regulatory & Candidacy Consultant Sherry Battiste at sherry.battiste@nscsw.org

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