Rural healthcare professionals' participation in Medical Assistance in Dying (MAiD): beyond a binary decision.

BACKGROUND: Medical Assistance in Dying (MAiD) was legalized in Canada in 2016 and amended in 2021. At the time that this study was conducted, the federal government was considering expanding the eligibility criteria to include patients whose death was not reasonably foreseeable. The purpose of this study was to better understand rural healthcare professionals' experiences with assisted dying set against the backdrop of legislative expansion. METHODS: A qualitative exploratory study was undertaken with general rural practice physicians, nurse practitioners, registered nurses, ethicists, patients, and patient families in rural Southern Alberta, Canada. For this paper, data from 18 audio-recorded and transcribed semi-structured interviews with healthcare professionals were analyzed using thematic analysis. Categories and patterns of shared meaning that linked to an overarching theme were identified. RESULTS: Between the binary positions of full support for and conscientious objection to assisted dying, rural healthcare professionals' decisions to participate in MAiD was based on their moral convictions, various contextual factors, and their participation thresholds. Factors including patient suffering; personal and professional values and beliefs; relationships with colleagues, patients and family, and community; and changing MAiD policy and legislation created nuances that informed their decision-making. CONCLUSIONS: The interplay of multiple factors and their degree of influence on healthcare professionals' decision-making create multiple decision points between full support for and participation in MAiD processes and complete opposition and/or abstention. Moreover, our findings suggest evolving policy and legislation have the potential to increase rural healthcare professionals' uncertainty and level of discomfort in providing services. We propose that the binary language typically used in the MAiD discourse be reframed to reflect that decision-making processes and actions are often fluid and situational.

Age-Friendly Communities: Are they also "Friendly" for Death, Dying, Grief, and Bereavement?

The age-friendly movement aims to ensure that people can live healthy and meaningful lives as they age. It is committed to activity and inclusion, with policies, services, and structures that enable older adults to remain engaged in activities that they value. We suggest that there is further opportunity for communities to increase inclusion and reduce ageism by improving their "death-friendliness". A death-friendly approach could lay the groundwork for a community in which people do not fear getting old or alienate those who have. To this end, we consider the merits of the compassionate communities framework which has emerged out of palliative care and critical public health. Compassionate communities focus on end-of-life planning, bereavement support, and improved understandings about aging, dying, death, loss, and care. The age-friendly and compassionate communities initiatives are complementary in their objectives but have not yet converged in practice. We suggest that they should.

Medical Assistance in Dying: A Review of Related Canadian News Media Texts.

Medical assistance in dying (MAiD) was legalized in Canada in 2016. Canadians' opinions on the service are nuanced, particularly as the legislation changes over time. In this paper, we outline findings from our review of representations of MAiD in Canadian news media texts since its legalization. These stories reflect the concerns, priorities, and experiences of key stakeholders and function pedagogically, shaping public opinion about MAiD. We discuss this review of Canadian news media on MAiD, provide examples of four key themes we identified (vulnerability, autonomy, dignity, and human rights), and discuss their implications for health policy and equity. Though key stakeholders share the values of autonomy, dignity, and human rights, they appeal to them in diverse ways, sometimes with conflicting policy demands. These representations offer a useful gauge of how views about MAiD continue to shift alongside changes in federal legislation. These stories can influence related policies, respond to the powerful voices that shape MAiD legislation, and have the potential to change national conversations. Our analysis adds to the existing body of scholarship on MAiD by examining post-Bill C-7 news media, identifying related health equity issues and tensions, and discussing potential impacts of MAiD's representations in news media.

Examining dual roles in long-term-care homes in rural Alberta: a qualitative study.

INTRODUCTION: In rural settings, many healthcare professionals experience intersections of professional and personal relationships, often known as dual roles. Dual roles are traditionally studied in terms of their potential for ethical conflicts or negative effects on care. In the existing scholarship, there is little discussion of dual roles in long-term care (LTC) settings, which present distinct conditions for care. Unlike other forms of health care, LTC work is provided daily, over longer periods, in care recipients' home environments. This article outlines results from a case study of LTC in rural Alberta, Canada and provides evidence of some of the challenges and, more notably, the considerable benefits of dual roles in these settings. METHODS: The qualitative data discussed in this article come from a multi-site comparative case study of rural LTC that, among other questions, asked, 'How do personal and professional lives intersect in rural LTC settings across the province?' These data were collected through the use of rapid ethnographies at three rural LTC homes across the province of Alberta. The research team conducted semi-structured, in-depth interviews (n=90) and field observations (~200 hours). Participants were asked about care team dynamics, the organization of care work, the role of the LTC home in the community, and the intersections of public and private lives. The results were coded and critically analyzed using thematic analysis. RESULTS: Dual roles were primarily described as beneficial for care provision. In many cases, dual roles provided participants with opportunities for reciprocity, enhanced person-centered care, and increased perceptions of trust and community accountability. Similar to what has been documented in the extant literature, dual roles also presented some challenges regarding personal and professional boundaries for those in leadership. However, the negative examples were outweighed by positive accounts of how dual roles can serve as a potential asset of rural LTC. CONCLUSION: There is a need for more nuanced conversations around the implications of dual roles. Policies and care approaches need to emphasize and support the use of good judgment and the responsible navigation of dual roles, rather than taking either a permissive or prohibitive approach. Leaders in rural LTC can promote conversations among care providers, with an emphasis on the cultural context of care provision and how dual roles play out in their specific professional practice. Blanket policies or educational approaches that frame dual roles as necessarily problematic are not only insensitive to the unique nature of rural LTC, but prohibitive of relational elements that these results suggest are highly supportive of person-centered care.

Sexual Expression in Alberta's Continuing Care Homes: Capacity, Consent, and Co-decision-making.

In this article, we explore the role of substitute decision-makers (SDMs) in matters of sexual expression for continuing care residents with diminished cognitive capacity. We examine how Alberta's current use of SDMs can enable an "all-or-none" approach to competence, wherein a person either has capacity to make all decisions or is incapable of making any. Three factors facilitate an environment in which this approach can influence residents' sexual expression. These include the wording of current legislation, lack of resources for SDMs, and relational dynamics between SDMs and care staff. We provide a critical review of existing legislation and empirical evidence of its challenges in practice. Though we focus on the Alberta context, there is reason to believe that similar issues persist in other Western jurisdictions. We offer several recommendations for how we can better support residents' sexual autonomy in continuing care and avoid pitfalls of the "all-or-none" approach to competence.

Consistent assignment in long-term care homes: Avoiding the pitfalls to capitalise on the promises.

BACKGROUND: Consistent assignment (CA) is the practice within long-term care (LTC) by which care staff work with the same residents almost every shift for an indefinite period of time. CA is considered by many to be essential to person-centred care. OBJECTIVES: This paper explores how staff assignment practices impact the caregiving experience from the perspectives of resident care aides (RCAs), residents and family members and, by doing so, describe the nuanced conditions under which CA may or may not be beneficial to all, and why. METHODS: Data are drawn from 40 in-depth interviews conducted as part of a larger institutional ethnography exploring the social organisation of care in three purposively selected LTC homes in Western Canada. Data analysis was based on the principles of constant comparison. RESULTS: RCAs, residents and family members described the primary benefit of CA as being able to 'get to know' each other well and form meaningful relationships. However, the RCAs also indicated that CA can contribute to feelings of isolation, which has negative effects on worker comfort and satisfaction, care team dynamics and communication, and resident care. CONCLUSIONS: Management initiatives are needed to ensure that the implementation of CA does not result in the unintended consequences of decreasing RCAs' experience of teamwork, decreasing RCAs' exchange of individualised resident care information, or negatively impacting RCAs' ability and desire to care for each other as well as the residents. IMPLICATIONS FOR PRACTICE: The staffing practice of consistent assignment in long-term care homes provides increased opportunities for the development of stronger staff-resident and staff-family member relationships. Findings from this study enable us to offer several, evidenced-based recommendations for ensuring the successful implementation of consistent assignment, such that it may be beneficial to all.

"If you do not find the world tasty and sexy, you are out of touch with the most important things in life": Resident and family member perspectives on sexual expression in continuing care.

Over the past three decades, there has been growing attention to sexual expression in continuing care homes. However, resident perspectives continue to be underrepresented, particularly in the Canadian context. In this article, we share findings from a qualitative, exploratory study looking at the experiences of residents and family members in Alberta, Canada. As continuing care demographics and social norms about sexuality shift, it is increasingly important to understand these perspectives. We asked participants about how they define sexual expression, its place in continuing care, their experiences with/thoughts about sexual expression in care homes, and suggestions for how to improve this aspect of resident life. We heard diverse accounts of what sexual expression can look like in continuing care homes, the importance of resident autonomy, how privacy matters, complex communication dynamics, and challenges with distinguishing between appropriate and inappropriate expressions. These findings foreground the voices of residents and family members and highlight key areas of opportunity for policy and practice change.

Experiences of moral distress by privately hired companions in Ontario's long-term care facilities.

PURPOSE: To explore long-term residential care provided by people other than the facilities' employees. Privately hired paid "companions" are effectively invisible in health services research and policy. This research was designed to address this significant gap. There is growing recognition that nursing staff in long-term care (LTC) residential facilities experience moral distress - a phenomenon in which one knows the ethically right action to take, but is systemically constrained from taking it. To date, there has been no discussion of the distressing experiences of companions in LTC facilities. This paper explores companions' moral distress. DESIGN: Data was collected using weeklong rapid ethnographies in seven LTC facilities in Southern Ontario, Canada. A feminist political economy analytic framework was used in the research design and in the analysis of findings. FINDINGS: Despite the differences in their work tasks and employment conditions, structural barriers can cause moral distress for companions. This mirrors the impacts experienced by nurses that are highlighted in the literature. Though companions are hired in order to fill care gaps in the LTC system, they too struggle with the current system's limitations. The hiring of private companions is not a sustainable or equitable solution to under-staffing and under-funding in Canada's LTC facilities. VALUE: Recognizing moral distress and the impact that it has on those providing LTC is critical in terms of supporting and protecting vulnerable and precarious care workers and ensuring high quality care for Canadians in LTC.

Scarcity discourses and their impacts on renal care policy, practices, and everyday experiences in rural British Columbia.

Drawing from a qualitative case study in rural British Columbia, Canada, this paper examines the discourse of kidney scarcity and its impact on renal care policies and practices. Our findings suggest that at different levels of care, there are different discourses and treatment foci. We have identified three distinct scarcity discourses at work. At the macro policy level, the scarcity of transplantable kidneys is the dominant discourse. At the meso health care institution level, we witnessed a discourse regarding the scarcity of health care and human resources. At the micro community level, there was a discourse of the scarcity of health and life-sustaining resources. For each form of scarcity, particular responses are encouraged. At the macro level, renal care and transplant organizations emphasize the benefits of kidney transplantation and procuring more donors. At the meso level, participants from the regional health care system increasingly encourage home hemodialysis and patient-led care. At the micro level, community health care professionals push for rural renal patients to attend dialysis and maintain their care plans. This work contributes to critical, interdisciplinary organ transfer discourse by contextualizing kidney scarcity. It reveals the tension between these discourses and the implications of pursuing kidney donations without addressing the conditions in which individuals experience kidney failure.

Domesticating dialysis: A feminist political economy analysis of informal renal care in rural British Columbia.

Drawing from a case study in rural British Columbia, this article examines the experiences of individuals providing unpaid care for family members on hemodialysis and how these experiences fit within larger political and socio-economic policy contexts. We suggest that the current shift towards home-based renal care, the "domestication of dialysis," reflects a broader trend toward a reduction of public health services, assumptions about the feasibility of unpaid care work in rural settings, and an increasing reliance on individuals-rather than the state-to support dependency and produce healthy citizens. This article confirms the challenges that come with providing daily care to a family member with a chronic disease and the gendered nature of unpaid care work. It also extends discussions of unpaid care to include how these challenges can be applied to renal care and complicated by rural residence.

Understanding action on the social determinants of health: a critical realist analysis of in-depth interviews with staff of nine Ontario public health units.

BACKGROUND: Addressing the social determinants of health (SDH) is identified as a role for local public health units (PHUs) in the province of Ontario. Despite this authorization to do so there is wide variation in PHU practice. In this article we consider the factors that shape local PHU action on the SDH through a critical realist analysis. METHODS: Interviews with Medical Officers of Health (MOHs) and lead staff from nine PHUs in Ontario identify the structures and powers that allow PHUs to address the SDH as well as the many factors that either activate or inhibit these structures and powers. RESULTS: We found that personal backgrounds and attitudes of MOHs and leading staff people as well as local jurisdictional characteristics shape whether and how PHUs carry out SDH-related activities. CONCLUSIONS: Action on the SDH is a result of a complex interplay of micro-, meso- and macro-level factors that requires recognition of the contested nature of public health, presence of Ministry of Health mandates, local jurisdictional characteristics, and politics. The most effective way to assure PHU action on the SDH is for the Ministry of Health and Long-Term Care to mandate such activities and develop accountability mechanisms that assure implementation.

Ideological and organizational components of differing public health strategies for addressing the social determinants of health.

Despite a history of conceptual contributions to reducing health inequalities by addressing the social determinants of health (SDH), Canadian governmental authorities have struggled to put these concepts into action. Ontario's-Canada's most populous province-public health scene shows a similar pattern. In statements and reports, governmental ministries, professional associations and local public health units (PHUs) recognize the importance of these issues, yet there has been varying implementation of these concepts into public health activity. The purpose of this study was to gain insight into the key features responsible for differences in SDH-related activities among local PHUs. We interviewed Medical Officers of Health (MOH) and key staff members from nine local PHUs in Ontario varying in SDH activity as to their understandings of the SDH, public health's role in addressing the SDH, and their units' SDH-related activities. We also reviewed their unit's documents and their organizational structures in relation to acting on the SDH. Three clusters of PHUs are identified based on their SDH-related activities: service-delivery-oriented; intersectoral and community-based; and public policy/public education-focused. The two key factors that differentiate PHUs are specific ideological commitments held by MOHs and staff and the organizational structures established to carry out SDH-related activities. The ideological commitments and the organizational structures of the most active PHUs showed congruence with frameworks adopted by national jurisdictions known for addressing health inequalities. These include a structural analysis of the SDH and a centralized organizational structure that coordinates SDH-related activities.