Nurse practitioner (NP) Erica Maynard of Nova Scotia brings her whole self to work, and that includes her role in medical assistance in dying (MAID) assessments and provisions. How does this procedure uniquely affect nurse practitioners, and what lessons have come up along the way during Erica’s journey? In this special post for the Dying With Dignity Canada blog, Erica shares her experiences working with patients to help them access their right to choice at end of life.
1. No, I am not a doctor, and no, I don’t have to be to assess/provide for MAID services.
As nurse practitioners, we are nurses who have baccalaureate and Master’s degrees. We have numerous years of nursing experience providing care to all age levels and degrees of illness. We have completed both didactic education and mentorship in order to provide medical assistance in dying. Federal legislation permits nurse practitioners to assess for and provide MAID, and each provincial college/health authority decided the process for competence. We are equal in knowledge and skills to our physician colleagues. Many people may not have had exposure to nurse practitioners in their healthcare journey. Since providing MAID, I am acutely aware of the need for ongoing public and professional education as to nurse practitioner scope of practice.
2. The relief that patients and families feel when they are qualified for MAID is overwhelming.
With cases that are very clear, I tend to tell the patient/family that they qualify right at the time of assessment (dependent on maintaining capacity, of course). The amount of physical and psychological relief that is displayed is amazing. Oftentimes, people cry and I can actually watch their postures relax. Of course, some family members are dismayed that their loved one qualified, as perhaps it would mean that they could spend extra time with them if they didn’t. The emotional rollercoaster and dynamics are incredible. It is always very interesting to arrive on the day of the provision. The person themselves is often relieved, happy, and so ready to see me. Family members are often acutely aware of the limited time remaining once I arrive. Whilst understanding, they are not so happy and relieved. Which leads me to my third lesson…
3. I am only human.
I try very hard to be professional during the assessments and the provisions. I like to maintain my calm exterior while my internal emotions may be churning in many different directions. My goal is to make both the patient and the families feel at ease as much as possible. However, at times, tears roll down my cheeks. I sometimes feel ashamed that I am crying. I try my best to hide the fact that this brief encounter with this patient and their family has had an impact on me. Sometimes I feel as if I do not have a right to infringe upon their grief with my own. After each provision, I tend to make notes about each encounter such as unique traits of the individual or things they loved. In this manner, I will always remember each person and family as individuals and not as cases. It tends to give me some closure and feels as though I have paid my respects to the loved one.
4. Assessing for and providing MAID is work unlike any other.
For years, we as healthcare providers focused on cures. When there was no cure, we focused on whatever comfort measures we could provide. Our aim was to keep people alive for as long as possible. I feel that providing MAID lets me help a suffering person when there aren’t any other viable options. I look at being able to spare someone last days that may be unthinkable as a privilege. To say that it is fulfilling work is an understatement. To say that the work is easy is a blatant untruth. What it is, though, is the ultimate form of helping when there are no other options.
5. The financial situation for NPs assessing for and providing MAID is complicated.
So, while I have discussed the educational and emotional requirements for this role, I have not touched on some of the political truths. One of those political truths involves renumeration for the work. Obviously, I am passionate enough about this work that I do it regardless of compensation. Most providers — both nurse practitioners and physicians — have been doing this work with very little compensation. Physician colleges across the country have been working with their provincial governments to develop billing codes and compensation framework. Most provinces now have a fee structure for their renumeration.
The majority of nurse practitioners are not “fee for service,” and therefore do not bill the government. We are mostly salaried employees of health authorities. We are usually in roles that demand a 40+ hour work week just doing our primary job. Most of us are doing MAID on the evenings and weekends because we have a calling to provide the service. Sometimes we can bank these working hours to have time off later, but most times, that is not practical due to the demands of our day jobs. In many provinces, nurse practitioners are not unionized, so there isn’t a collective agreement procedure to address the overtime/lack of renumeration. In provinces where nurse practitioners are unionized, there is a movement towards being able to claim overtime for hours worked. Our physician colleagues see the injustice in the renumeration between the two professions. They advocate for nurse practitioners, but at the end of the day, there is only so much funding to go around.
I do not want my fiscal rant to take priority in this piece. I want patients, families, colleagues, supporters, protesters, or whomever to realize that nurse practitioners are here in Canada and we are playing a vital role in both your health and death. We provide competent, compassionate care that is second rate to none, and we are honoured to have such a pivotal role assessing for and providing MAID.
Erica Maynard, Nurse Practitioner
We extend our deepest thanks to Erica Maynard for sharing her valuable lessons and insights with our community. We are immensely grateful to nurse practitioners across the country, like Erica, who are providing such compassionate, patient-centred care. Thank you!