Medical assistance in dying in Canada: A scoping review on the concept of suffering.

OBJECTIVES: Medical Assistance in Dying (MAiD) has been legal in Canada since June 2016. A person can receive MAiD if their suffering cannot be relieved under conditions that they consider acceptable. Informed consent requires that the person requesting MAiD has received all the information needed to make their decision; that is, medical diagnosis and prognosis, available treatments including palliative care. The evaluation of unbearable suffering is known to be challenging as suffering is often psychological, existential, and social in nature. While interventions to relieve suffering exist, it is unclear how suffering is assessed and addressed in the literature on MAiD practice. No scoping review exists on the topic in Canada. The aim of this study was to understand how the concept of suffering was approached within the Canadian MAiD grey (GL) and scientific (peer-reviewed) literature (SL), specifically: 1- How suffering is defined and assessed in the context of MAiD in Canada and 2- Which interventions in response to suffering are recommended within the process of obtaining informed consent for MAiD and throughout the process of MAiD itself. METHODS: A scoping review was conducted based on PRISMA-SR guidelines. SL articles (N = 1027) were identified from a review of 6 databases and GL documents (N = 537) were obtained from the provinces of Quebec, Ontario and British Columbia. Documents were analyzed using NVivo with coding by two-raters and continuous team discussions. RESULTS: A multidimensional definition of suffering, akin to the concept of total pain, is used. The assessment of suffering is based upon patients' reports. Tools to aid in the assessment are not comprehensively covered. Specific interventions to address suffering were often focused on active listening and the management of physical symptoms. No specific interventions were mentioned and there was no reference to clinical practice guidelines in the grey literature to address other components of suffering. The use of a multidisciplinary approach is suggested without specifying the nature of involvement. CONCLUSIONS: Our review indicates that published guidelines of MAID assessments could include clearer structure around the assessment and management of suffering, with suggestions of tools that may help clarify types of suffering and reference to clinical practice guidelines and interventions to holistically attend to patient suffering with an attention on non-physical symptoms. Guidelines would benefit from clearer explanations of how members of an interdisciplinary teams could be coherently coordinated.

Outcomes of Community-Based Suicide Prevention Approaches That Involve Reducing Access to Pesticides: A Systematic Literature Review.

OBJECTIVE: Pesticide ingestion is among the most commonly utilized means of suicide worldwide. Restricting access to pesticides at a local level is one strategy to address this major public health problem, but little is known about its effectiveness. We therefore conducted a systematic literature review to identify effective community-based suicide prevention approaches that involve restricting access to pesticides. METHOD: We searched Embase, Scopus, PsycINFO, Cochrane Library, CINAHL, and PubMed for well-designed studies that reported on suicide-related outcomes (i.e., attempted or completed suicide). RESULTS: We identified only five studies that met our eligibility criteria (two randomized controlled trials, two studies with quasi-experimental designs, and one study with a before-and-after design). These studies tested different interventions: the introduction of nonpesticide agricultural management, providing central storage facilities for pesticides, distributing locked storage containers to households, and local insecticide bans. The only sufficiently powered study produced no evidence of the effectiveness of providing household storage containers. Three interventions showed some promise in reducing pesticide suicides or attempts, with certain caveats. CONCLUSIONS: Our review identified three community interventions that show some promise for reducing pesticide suicides by restricting access to means, which will require replication in large, well-designed trials before they can be recommended.