Care considerations in medical assistance in dying for persons with mental illness as the sole underlying medical condition: a qualitative study of patient and family perspectives

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Several participants commented on the impact of social determinants of health on symptom burden and that addressing those first might be key to determining irremediability.

“Several participants commented on the impact of the social determinants of health on symptom burden and how addressing those first might be key to determining irremediability”

Probably not a substantial claim.

Participants identified the importance of providers enhancing their understanding of issues such as poverty, loneliness and marginalization, so they can better appreciate what could be addressed to alleviate suffering.

“Finally, they identified the importance of providers enhancing their understanding of issues such as poverty, loneliness and marginalization, so they can better appreciate what could be addressed to alleviate suffering.”

Probably not a substantial claim.

Participants outlined the need for a diagnostic assessment, to confirm the diagnosis of a mental illness and establish its chronicity, current symptom burden and their impact.

“Participants outlined the need for a diagnostic assessment, to confirm the diagnosis of a mental illness and establish its chronicity, current symptom burden and their impact.”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Several participants spoke to the need to assess suicidality.

“Several participants spoke to the need to assess suicidality”

Probably not a substantial claim.

Participants spoke to the need to assess clarity of mind and capacity to make treatment decisions.

“Participants also spoke to the need to assess “clarity of mind” (F10) and capacity to make treatment decisions.”

It may state two separate claims as one.

Participant narratives underscored hopes for compassion, appreciation of one's autonomy, consideration of one's support environment, and an understanding for the social determinants of health in the assessment process.

“Participant narratives underscored hopes for compassion, appreciation of one’s autonomy, consideration of one’s support environment, and an understanding for the social determinants of health in the assessment process.”

Probably not a substantial claim.

Many participants emphasized the need for assessors to have deep knowledge and understanding of mental health and mental illness.

“Many participants emphasized the need for assessors to have deep knowledge and understanding of mental health and mental illness.”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Participants highlighted the support that peers or advocates could offer in the assessment process.

“In addition to professionals, they highlighted the support that peers or advocates could offer”

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Participants expressed concern that some providers may not want to offer assistance in accessing MAiD MI-SUMC due to their personal or religious views, or that they may discourage patients or stigmatize MAiD MI-SUMC.

“Participants expressed concern that some providers may not want to offer assistance in accessing MAiD MI-SUMC due to their personal or religious views, or that they may discourage patients or stigmatize MAiD MI-SUMC.”

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Other participants suggested that a health care provider could mention MAiD MI-SUMC in the context of unbearable suffering, a trusting patient-provider relationship, and in a late stage of illness that has not responded to available treatments after many years, if in alignment with patient values and goals of care.

“Other participants suggested that a health care provider could mention MAiD MI-SUMC in the context of unbearable suffering, a trusting patient-provider relationship, and in a late stage of illness that has not responded to available treatments after “many years” (P4), if in alignment with patient values and goals of care.”

Probably not a substantial claim.

Several participants questioned whether family physicians or nurse practitioners have the expertise or are qualified to assess the adequacy of past mental health treatments and what treatments could yet be tried.

“several participants questioned whether family physicians or nurse practitioners “have the expertise” (P10) needed or “are qualified” (P11) to assess the adequacy of past mental health treatments and what treatments could yet be tried.”

Probably not a substantial claim. It may state two separate claims as one.

Both patient and family member participants expressed that providers would need to provide both information and guidance to patients planning a formal MAiD request, within person-centred encounters that are trauma-informed, validate experiences of suffering, and convey active listening and hope for recovery.

“Both patient and family member participants expressed that providers would need to provide both information and guidance to patients planning a formal MAiD request, within person-centred encounters that are trauma-informed, validate experiences of suffering, and convey active listening and hope for recovery.”

Probably not a substantial claim. It may state two separate claims as one.

Participants highlighted the importance of assessing the applicant's quality of life, and of exploring strategies to bring meaning and joy.

“they highlighted the importance of assessing the applicant’s quality of life, and of exploring strategies to bring meaning and joy”

It may state two separate claims as one.

The six themes highlighted a congruence of views between patient and family members and described key desired process ingredients, including a person-centred non-judgmental stance by care providers, inter-professional holistic care, shared decision making, and the primacy of patient autonomy in healthcare decision making.

“These themes highlighted a congruence of views between patient and family members and described key desired process ingredients, including a person-centred non-judgmental stance by care providers, inter-professional holistic care, shared decision making, and the primacy of patient autonomy in healthcare decision making.”

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Both patient and family member participants spoke to the need for raising public awareness and making broadly available patient-facing information, including pamphlets in providers' offices.

“Both patient and family member participants spoke to the need for raising public awareness and making broadly available patient-facing information, including pamphlets in providers’ offices.”

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Some participants linked irremediability with finding hope (or not), with contrasting views expressed regarding hope in the context of mental illness.

“Some participants linked irremediability with finding hope (or not), with contrasting views expressed regarding hope in the context of mental illness.”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Some participants described the value of pre-assessing capacity to consent, before further evaluation, to ensure that the individual has capacity to make treatment decisions.

“Some participants described the value of pre-assessing capacity to consent, before further evaluation, to ensure that the individual has capacity to make treatment decisions”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Participants commented on the importance of outside consultations, including consultations with the applicant's primary mental health care providers and case workers or counselors.

“The importance of outside consultations was also commented upon by several participants, including consultations with the applicant’s primary mental health care providers and case workers or counselors.”

Probably not a substantial claim. The authors may not put it forward as true. It may state two separate claims as one.

Clinician-led psychoeducation for patients around MAiD MI-SUMC should outline eligibility criteria, steps for submitting a request, details on the assessment process, anticipated timelines, and the different options for administering MAiD.

“they commented that clinician-led psychoeducation for patients around MAiD MI-SUMC should outline eligibility criteria, steps for submitting a request, details on the assessment process, anticipated timelines, and the different options for administering MAiD.”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Participants identified that providers biased against MAiD MI-SUMC should not be involved in the assessment process.

“They further identified that those providers biased against MAiD MI-SUMC should not be involved in the assessment process”

Probably not a substantial claim.

Participants spoke of the need to assess the consistency of the request over time to ensure that it is a decision reached over a long period of time and not a knee-jerk reaction.

“Participants finally spoke of the need to assess the consistency of the request over time to ensure that it is a decision reached over “a long period of time” (P16) and not “like a knee-jerk reaction to something happening or a symptom popping up…” (F1)”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Participants described the need for education about other forms of relief, including new and emerging or experimental treatments.

“They also described the need for education about other forms of relief, including new and emerging or experimental treatments”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Several participants commented that health providers should have and display a deep understanding of the social determinants of health, and their impact on mental health, in their interactions with patients.

“Several participants also commented that health providers should have and display a deep understanding of the social determinants of health, and their impact on mental health, in their interactions with patients.”

It may state two separate claims as one.

Most participants expressed strong preferences that assessors be psychiatrists, supported by a team or a panel of additional providers to address the psychiatric, psychological, social, spiritual and relational aspects of patients' experiences and suffering.

“Most participants expressed strong preferences that assessors be psychiatrists, supported by a team or a panel of additional providers to address the psychiatric, psychological, social, spiritual and relational aspects of patients’ experiences and suffering.”

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Some participants expressed the view that families might not appreciate the extent of the suffering their loved one with mental illness is experiencing, or that they may try to sway them to keep them alive, threatening their autonomy.

“Some participants expressed the view that families might not appreciate the extent of the suffering their loved one with mental illness is experiencing, or that they may “try to sway them” (F1) to keep them alive, threatening their autonomy”

Probably not a substantial claim.

Participants commented on the importance of assessors having knowledge of the patient directly, or by connecting to their support teams.

“Finally, participants commented on the importance of assessors having knowledge of the patient directly, or by connecting to their support teams”

It may state two separate claims as one.

Many participants highlighted that MAiD MI-SUMC is not a treatment, and should not be presented as a treatment option, but rather discussed as a last resort to alleviate suffering once all other options have been exhausted.

“Many participants highlighted that MAiD MI-SUMC is not a treatment, and should not be presented as a treatment option, but rather discussed as a last resort to alleviate suffering once all other options have been exhausted.”

Probably not a substantial claim. The authors may not put it forward as true. The paper’s conclusions may not depend on it.

Other participants contended that in mental health there is always hope.

“Other participants contended that in mental health there is always hope”

It may state two separate claims as one.

Patients and families were similarly aligned in discussions of the most appropriate MAiD MI-SUMC assessment team composition and of the role of families and social supports in the assessment process.

“Patients and families were similarly aligned in discussions of the most appropriate MAiD MI-SUMC assessment team composition and of the role of families and social supports in the assessment process.”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Several participants voiced that MAiD conversations should only be initiated by patients themselves.

“Several participants voiced that MAiD conversations should only be initiated by patients themselves”

It may state two separate claims as one.

Both patient and family member participants emphasized the value of comprehensive, person-centred assessments, inclusive of medical history, life circumstances, presence (or absence) of social and family supports, assessment of acute suicidality, and the primacy of the subjective experience of suffering.

“Both patient and family member participants emphasized the value of comprehensive, person-centred assessments, inclusive of medical history, life circumstances, presence (or absence) of social and family supports, assessment of acute suicidality, and the primacy of the subjective experience of suffering.”

Probably not a substantial claim. The authors may not put it forward as true. The paper’s conclusions may not depend on it.

Some family members expressed the view that they should be part of the application process, as they may be able to give important input as to the duration of suffering and quality of life.

“On the other hand some family members expressed the view that they should be part of the application process, as they may be able to give important input as to the duration of suffering and quality of life”

Probably not a substantial claim. It may state two separate claims as one.

Participants spoke of the need to explore the presence (or not) of family and social support, and opportunities to augment these supports.

“They also spoke of the need to explore the presence (or not) of family and social support, and opportunities to augment these supports.”

Probably not a substantial claim.

Participants identified the primacy of the applicant's own assessment of their suffering as the baseline of eligibility.

“They identified the primacy of the applicant’s own assessment of their suffering, as this participant expressed:“‘I perceive my own suffering and my own anguish as intolerable to the point where I wish to end my life.’ That should be the baseline of eligibility.” (F7).”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Participants described that assessors would ideally inform MAiD MI-SUMC applicants of experimental treatments and refer them to potentially helpful treatments as well as peer support.

“They described that assessors would ideally inform MAiD MI-SUMC applicants of experimental treatments and refer them to potentially helpful treatments as well as peer support.”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Participants commented on treatments not yet attempted and new and emerging treatments that may provide relief.

“Lastly, participants commented on treatments not yet attempted and new and emerging treatments that may provide relief.”

Probably not a substantial claim. It may state two separate claims as one.

Participants highlighted that MAiD MI-SUMC should not be described as a quick fix, but rather providers should discuss the pros and cons, including its irreversibility once administered, and MAiD's impact on others.

“Finally, they highlighted that MAiD MI-SUMC should not be described “as a quick fix” (F1), but rather providers should discuss the pros and cons, including its irreversibility once administered, and MAiD’s impact on others.”

Probably not a substantial claim. It may state two separate claims as one.

Participants highlighted the importance of a neutral stance, with providers not trying to persuade patients in either direction, focusing on patient needs and preferences.

“They highlighted the importance of a neutral stance, with providers not trying to persuade patients in either direction, focusing on patient needs and preferences”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Some participants identified ongoing suicidality as a reason to reassess and grant a MAiD MI-SUMC request, as a preferred way to die.

“Some participants identified ongoing suicidality as a reason to reassess and grant a MAiD MI-SUMC request, as a preferred way to die”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Some participants proposed an appeal process and access to alternate opinions, following a denied request.

“Some participants proposed an appeal process and access to alternate opinions, following a denied request.”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

A few participants questioned the legal framework and the basis upon which providers could find a person ineligible.

“a few participants questioned the legal framework and the basis upon which providers could find a person ineligible”

It may state two separate claims as one.

The majority of participants favored the right to reapply for MAiD MI-SUMC, with proposed wait periods ranging from weeks to several years.

“The majority of participants favored the right to reapply for MAiD MI-SUMC, with proposed wait periods ranging from weeks to several years.”

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Some participants proposed that a request reversal should just put things on hold, with the ability to resume the MAiD MI-SUMC process where it was left off at any time, while others commented that a withdrawal should impact future eligibility to reapply, or necessitate a waiting period before re-applying.

“Although some proposed that a request reversal should just put things on hold, with the ability to resume the MAiD MI-SUMC process where it was left off at any time, others commented that a withdrawal should impact future eligibility to reapply, or necessitate a waiting period before re-applying.”

It may state two separate claims as one.

Participants commented on the information and support needs of approved MAiD MI-SUMC applicants, their need for ongoing care, provisions for possible request withdrawals, and support for families.

“Patient and family member participants commented on the information and support needs of approved MAiD MI-SUMC applicants, their need for ongoing care, provisions for possible request withdrawals, and support for families.”

It may state two separate claims as one.

Participants stressed the importance of holistic, interdisciplinary assessments, and the opportunity to tell their story and exercise autonomous health decision making.

“Similarly, in keeping with prior research with patients with other health conditions and their families, participants stressed the importance of holistic, interdisciplinary assessments, and the opportunity to tell their story and exercise autonomous health decision making [25, 49].”

• cites [25] Brown J, Goodridge D, Harrison A, Kemp J, Thorpe L, Weiler R. Care considerations in a patient and family centered medical assistance in dying program. J Palliat Care. 2022;37(3):341–51. sourceNot checked yet
• cites [49] Pronk R, Willems DL, van de Vathorst S. Feeling seen, being heard: perspectives of patients suffering from mental illness on the possibility of physician-assisted death in the Netherlands. Cult Med Psychiatry. 2022;46(2):475–89. sourceNot checked yet

It may state two separate claims as one.

Persons with mental illness and family participants were aligned in their views on MAiD MI-SUMC service delivery, with a variety of perspectives expressed within both groups in our study.

“Persons with mental illness and family participants were aligned in their views on MAiD MI-SUMC service delivery, with a variety of perspectives expressed within both groups in our study [35, 41, 42].”

• cites [35] Bastidas-Bilbao H, Stergiopoulos V, van Kesteren MR, Stewart DE, Cappe V, Gupta M, et al. Searching for relief from suffering: a patient-oriented qualitative study on medical assistance in dying for mental illness as the sole underlying medical condition. Soc Sci Med. 2023;331:116075. sourceNot checked yet
• cites [41] Bastidas-Bilbao H, Stergiopoulos V, Cappe V, van Kesteren MR, Stewart DE, Gupta M, et al. Walking alongside: views of Family members on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition. Qual Health Res. 2023;33(13):1140–53. sourceNot checked yet
• cites [42] Hawke LD, Bastidas-Bilbao H, Cappe V, van Kesteren MR, Stewart DE, Gupta M et al. Medical assistance in dying for Mental Illness as a Sole Underlying Medical Condition and its relationship to suicide: a qualitative lived experience-engaged study. Can J Psychiatry.0(0):07067437231209658.Not checked yet

It may state two separate claims as one.

Participants underscored the importance of hope in alleviating suffering and suggested ongoing and additional services and supports to MAiD MI-SUMC applicants throughout the assessment period.

“They underscored the importance of hope in alleviating suffering and suggested ongoing and additional services and supports to MAiD MI-SUMC applicants throughout the assessment period.”

Probably not a substantial claim.

Several study participants viewed suicidal ideation as a reason to grant, rather than refuse MAiD MI-SUMC, considering it a better, more dignified option to the painful and uncertain death by suicide for those intent on ending their life.

“Notably, several study participants viewed suicidal ideation as a reason to grant, rather than refuse MAiD MI-SUMC, considering it a better, more dignified option to the painful and uncertain death by suicide for those intent on ending their life [62, 63].”

• cites [62] Hawk M, Coulter RWS, Egan JE, Fisk S, Reuel Friedman M, Tula M, et al. Harm reduction principles for healthcare settings. Harm Reduct J. 2017;14(1):70. sourceNot checked yet
• cites [63] Wiebe K, Mullin A. Choosing death in unjust conditions: hope, autonomy and harm reduction. J Med Ethics. 2023. sourceNot checked yet

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Others suggested no wait time after completion of the eligibility assessment, or a wait time chosen by the patient.

“Others suggested no wait time after completion of the eligibility assessment, or a wait time chosen by the patient.”

Probably not a substantial claim. It may state two separate claims as one.

Participants called for MAiD public awareness raising and patient psychoeducation, assessment teams and processes that unpack "the story" and minimize suffering, with special attention to the assessment aftermath.

“Participants called for MAiD public awareness raising and patient psychoeducation, assessment teams and processes that unpack “the story” and minimize suffering, with special attention to the assessment aftermath.”

Probably not a substantial claim.

There was consensus that following a request withdrawal, applicants should be connected to services and supports to understand the rationale for their decision and to develop appropriate care plans, including access to new or untried treatments.

“There was consensus that following a request withdrawal, applicants should be connected to services and supports to understand the rationale for their decision and to develop appropriate care plans, including access to new or untried treatments.”

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Some participants envisioned that efforts during the waiting period might be geared towards changing applicants' minds and helping with MAiD MI-SUMC request withdrawals, while others described individual or group supports and interventions to set applicants' affairs in order or in preparation for death and dying.

“Although some envisioned that efforts during this period might be geared towards changing applicants’ minds and helping with MAiD MI-SUMC request withdrawals, others described individual or group supports and interventions to set applicants’ affairs in order, or in preparation for death and dying”

It may state two separate claims as one.

Participants identified key care ingredients throughout the MAiD MI-SUMC process, including a person-centred non-judgmental stance by care providers, inter-professional holistic care, shared decision-making, and the primacy of patient autonomy.

“They also identified key care ingredients throughout the MAiD MI-SUMC process, including a person-centred non-judgmental stance by care providers, inter-professional holistic care, shared decision-making, and the primacy of patient autonomy.”

It may state two separate claims as one.

There was widespread agreement among participants on the value of clinicians responding to patient-initiated MAiD MI-SUMC questions using a non-judgmental stance, but participants voiced conflicting views on clinicians introducing MAiD in goals of care discussions with persons with a mental illness.

“Although there was widespread agreement on the value of clinicians responding to patient-initiated MAiD MI-SUMC questions using a non-judgmental stance, participants voiced conflicting views on clinicians introducing MAiD in goals of care discussions with persons with a mental illness.”

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Participants commented that request withdrawals should be treated with compassion and respect, with a wide range of opinions among both patient and family member participants regarding implications of such withdrawals for future eligibility.

“Participants also commented that request withdrawals should be treated with compassion and respect, with a wide range of opinions among both patient and family member participants regarding implications of such withdrawals for future eligibility.”

Probably not a substantial claim. It may state two separate claims as one.

Participants discussed the importance of ongoing treatment and supports throughout the process, with periodic check-ins, re-assessments of capacity, and reminders of the voluntariness of the request and hence the possibility of a MAiD MI-SUMC request withdrawal.

“They discussed the importance of ongoing treatment and supports throughout the process, with periodic check-ins, re-assessments of capacity, and reminders of the voluntariness of the request and hence the possibility of a MAiD MI-SUMC request withdrawal.”

It may state two separate claims as one.

Although participants acknowledged the need for experts to assist in assessing irremediability, they focused on the patient's lived expertise, attempted treatments, the role of social determinants and their interaction with illness experience and trajectories, and shared decision-making in MAiD MI-SUMC eligibility assessments.

“Although they acknowledged the need for experts to assist in assessing irremediability, ultimately, they focused on the patient’s lived expertise, attempted treatments, the role of social determinants and their interaction with illness experience and trajectories, and shared decision-making in MAiD MI-SUMC eligibility assessments.”

Probably not a substantial claim. The authors may not put it forward as true. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Other opinions proposed that MAiD assessors should also anticipate such outcomes and bear accountability.

“Other opinions proposed that MAiD assessors should also anticipate such outcomes and bear accountability”

Probably not a substantial claim. It may state two separate claims as one.

Participants expressed that assessors would need to offer detailed information about next steps following the MAiD MI-SUMC eligibility assessment, while putting patient preferences first and minimizing suffering.

“participants expressed that assessors would need to offer detailed information about next steps following the MAiD MI-SUMC eligibility assessment, while putting patient preferences first, and minimizing suffering”

It may state two separate claims as one.

Both patients and family member participants described an expectation of marked distress, including increased suicidality, and either increased efforts to get well or attempts to worsen one's situation so they become eligible for MAiD MI-SUMC following a denied request.

“Both patients and family member participants described an expectation of marked distress, including increased suicidality, and either increased efforts to get well or attempts to worsen one’s situation so they become eligible for MAiD MI-SUMC following a denied request.”

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

In the context of expected distress after denial, there were suggestions for follow-ups and wellness checks to monitor for suicidality, with a range of views expressed on managing suicidality.

“In this context, there were suggestions for follow-ups and wellness checks to monitor for suicidality, with a range of views expressed on managing suicidality.”

Probably not a substantial claim. The authors may not put it forward as true. The paper’s conclusions may not depend on it.

Some participants suggested that treating providers should be held accountable, or even lose their license, if a person that has been under their care requests MAiD MI-SUMC and commits suicide after being denied.

“Some participants suggested that treating providers should be held accountable, or even “lose their license” (F13), if a person that has been under their care requests MAiD MI-SUMC and commits suicide after being denied.”

Probably not a substantial claim. The authors may not put it forward as true. The paper’s conclusions may not depend on it.

Others suggested that acute suicidality following a denied request should trigger existing suicide prevention strategies, including involuntary hospitalization to keep someone safe.

“Others suggested that acute suicidality following a denied request should trigger existing suicide prevention strategies, including involuntary hospitalization to keep someone safe”

Probably not a substantial claim. It may state two separate claims as one.

Our findings highlight the primacy of person-centred holistic assessment paradigms, and the importance of shared decision making and patient autonomy in MAiD MI-SUMC considerations.

“Our findings highlight the primacy of person-centred holistic assessment paradigms, and the importance of shared decision making and patient autonomy in MAiD MI-SUMC considerations.”

Probably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.

Our findings identify the need for ongoing public education, the development of practice guidelines to bring together the diverse perspectives of all stakeholders, and assessment processes that minimize suffering and attend to the eligibility assessment aftermath.

“Our findings also identify the need for ongoing public education, the development of practice guidelines to bring together the diverse perspectives of all stakeholders, and assessment processes that minimize suffering and attend to the eligibility assessment aftermath.”

Probably not a substantial claim. It may be too vague to check against evidence.

These stakeholders' perspectives will continue to be essential in MAiD MI-SUMC implementation efforts, to better address the needs of diverse communities and inform improvement efforts.

“These stakeholders’ perspectives will continue to be essential in MAiD MI-SUMC implementation efforts, to better address the needs of diverse communities and inform improvement efforts.”

• AssumptionRests on an assumption: Patient and family perspectives are central to delivering high-quality MAiD MI-SUMC programs and should complement professional practice standards.
• AssumptionRests on an assumption: The perspectives of patients and family members in Ontario are relevant to MAiD MI-SUMC implementation in Canada.

Probably not a substantial claim. The paper’s conclusions may not depend on it.

The results are reported in accordance with the Standards for Reporting Qualitative Research (SRQR).

“The results are reported in accordance with the Standards for Reporting Qualitative Research (SRQR) [33].”

• cites [33] O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51. sourceNot checked yet

Probably not a substantial claim. The paper’s conclusions may not depend on it.

A lived-experience advisory group contributed to every aspect of the study, from planning to recruitment, analysis and reporting.

“This lived-experience advisory group contributed to every aspect of the study, from planning to recruitment, analysis and reporting, with two of the advisors co-authoring this manuscript.”

• Also stated in: § Methods · plain

  “A lived-experience advisory group participated in every aspect of this study.”

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

The interview guide was piloted and a member of the lived-experience advisory group provided feedback on the pilot interview video recording before finalizing the guide.

“The interview guide was piloted and a member of our lived-experience advisory group provided feedback on the pilot interview video recording before finalizing the interview guide.”

Probably not a substantial claim. It may be too vague to check against evidence.

Family and patient perspectives on the implementation of MAiD MI-SUMC offer important considerations for service planning that could complement existing and emerging professional practice standards.

“Family and patient perspectives on the implementation of MAiD MI-SUMC offer important considerations for service planning that could complement existing and emerging professional practice standards.”

• AssumptionRests on an assumption: Patient and family perspectives are central to delivering high-quality MAiD MI-SUMC programs and should complement professional practice standards.
• AssumptionRests on an assumption: The perspectives of patients and family members in Ontario are relevant to MAiD MI-SUMC implementation in Canada.

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Data analysis was led by HB and supported by a data analysis working group that met biweekly to discuss emerging codes and themes, and resonance with practice and lived experience.

“Data analysis was led by HB, and was supported by a data analysis working group that met biweekly to discuss emerging codes and themes, and resonance with practice and lived experience.”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

Recruitment targets aimed to balance pragmatic considerations with the opportunity to enhance diversity of perspectives and experiences and promote information redundancy.

“Recruitment targets aimed to balance pragmatic considerations with the opportunity to enhance diversity of perspectives and experiences and promote information redundancy.”

Probably not a substantial claim.

In Canada, people experiencing mental illness as their sole underlying medical condition are anticipated to be eligible to request MAiD as of March 17, 2024.

“In Canada, it is anticipated that people experiencing a mental illness as their sole underlying medical condition will be eligible to request MAiD as of March 17th, 2024 [17].”

• cites [17] Government of Canada. Bill C-39. An act to amend an act to amend the criminal code (medical assistance in dying) 2023 [Available from: https://www.parl.ca/legisinfo/en/bill/44-1/c-39.Not checked yet

Probably not a substantial claim. The paper’s conclusions may not depend on it.

The study received approval from the Research Ethics Board of the Centre for Addiction and Mental Health in Ontario, Canada.

“The study received approval from the Research Ethics Board of the Centre for Addiction and Mental Health in Ontario, Canada.”

Probably not a substantial claim. The paper’s conclusions may not depend on it.

The semi-structured interview guide, based on a persona-scenario exercise, was developed using participatory approaches, including input from lived-experience advisors.

“The semi-structured interview guide [35], based on a persona-scenario exercise (PSE) [36] to facilitate participant engagement, was developed using participatory approaches, including input from our lived-experience advisors.”

• cites [35] Bastidas-Bilbao H, Stergiopoulos V, van Kesteren MR, Stewart DE, Cappe V, Gupta M, et al. Searching for relief from suffering: a patient-oriented qualitative study on medical assistance in dying for mental illness as the sole underlying medical condition. Soc Sci Med. 2023;331:116075. sourceNot checked yet
• cites [36] Valaitis R, Longaphy J, Nair K, Agarwal G, Griffith L, Kastner M, et al. Persona-scenario exercise for codesigning primary care interventions. Can Fam Physician. 2014;60(3):294–6.Not checked yet

Probably not a substantial claim. The paper’s conclusions may not depend on it.

At the time of the study, it was not known whether additional safeguards for MAiD MI-SUMC would be put in place in Canada.

“At this time, it is not known whether additional safeguards for MAiD MI-SUMC will be put in place in Canada [21].”

• cites [21] Health Canada. Final report of the expert panel on MAiD and mental illness 2022 [Available from: https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/expert-panel-maid-mental-illness/final-report-expert-panel-maid-mental-illness/final-report-expert-panel-maid-mental-illness.pdf.Not checked yet

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

Recent studies highlight the need for holistic, interdisciplinary care, relationship building and anticipatory guidance throughout the process, as well as bereavement supports for family and loved ones, and dedicated space for MAiD provision.

“Recent studies have also highlighted the need for holistic, interdisciplinary care, relationship building and anticipatory guidance throughout the process, as well as bereavement supports for family and loved ones, and dedicated space for MAiD provision [25–27].”

• cites [25] Brown J, Goodridge D, Harrison A, Kemp J, Thorpe L, Weiler R. Care considerations in a patient and family centered medical assistance in dying program. J Palliat Care. 2022;37(3):341–51. sourceNot checked yet
• cites [26] Hales BM, Bean S, Isenberg-Grzeda E, Ford B, Selby D. Improving the medical assistance in dying (MAID) process: a qualitative study of family caregiver perspectives. Palliat Support Care. 2019;17(5):590–5. sourceNot checked yet
• cites [27] Dees MK, Vernooij-Dassen MJ, Dekkers WJ, Elwyn G, Vissers KC, van Weel C. Perspectives of decision-making in requests for euthanasia: a qualitative research among patients, relatives and treating physicians in the Netherlands. Palliat Med. 2013;27(1):27–37. sourceNot checked yet

It may state two separate claims as one.

The literature suggests that many MAiD applicants report ongoing suicidal ideation following a denied MAiD request, calling for follow-up assessments and safety planning following the MAiD assessment.

“The literature suggests that many MAiD applicants report ongoing suicidal ideation following a denied MAiD request [61], calling for follow-up assessments and safety planning following the MAiD assessment.”

• cites [61] Pasman HR, Willems DL, Onwuteaka-Philipsen BD. What happens after a request for euthanasia is refused? Qualitative interviews with patients, relatives and physicians. Patient Educ Couns. 2013;92(3):313–8. sourceNot checked yet

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

The Canadian Association of MAiD Assessors and Providers supports informing eligible patients about MAiD, highlighting the value of informed consent, the importance of patient autonomy, and the role of clinicians as gatekeepers of clinical information.

“the Canadian Association of MAiD Assessors and Providers supports informing eligible patients about MAiD, highlighting the value of informed consent, the importance of patient autonomy, and the role of clinicians as gatekeepers of clinical information [44].”

• cites [44] Brassfield ER, Buchbinder M. Clinical discussion of Medical Aid-in-Dying: minimizing harms and ensuring informed choice. Patient Educ Couns. 2021;104(3):671–4. sourceNot checked yet

Probably not a substantial claim.

This study adds to the limited literature on the perspectives of persons with mental illness and their families on MAiD MI-SUMC care processes and their implications for practice.

“This study, using rigorous qualitative methods and participatory engagement processes, adds to the limited literature on the perspectives of persons with mental illness and their families on MAiD MI-SUMC care processes, and their implications for practice.”

It may state two separate claims as one.

Participant narratives aligned with prior research suggesting that patients value clinician openness in discussions on MAiD, transparency about the legal framework and the assessment process, and maintenance of clinician-patient relationship, even when clinician and patient disagree about MAiD.

“participant narratives aligned with prior research suggesting that patients value clinician openness in discussions on MAiD, transparency about the legal framework and the assessment process, and maintenance of clinician-patient relationship, even when clinician and patient disagree about MAiD [43].”

• cites [43] Back AL, Starks H, Hsu C, Gordon JR, Bharucha A, Pearlman RA. Clinician-patient interactions about requests for physician-assisted suicide: a patient and family view. Arch Intern Med. 2002;162(11):1257–65. sourceNot checked yet

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

These participants placed greater emphasis on patient choice and self-determination that is articulated in MAiD legislation in Canada, with views and perspectives in keeping with de-medicalized assisted suicide services, where access to assisted death is patient determined.

“These participants placed greater emphasis on patient choice and self-determination that is articulated in MAiD legislation in Canada, with views and perspectives in keeping with de-medicalized assisted suicide services, where access to assisted death is patient determined [64].”

• cites [64] Hagens M, Pasman HRW, Onwuteaka-Philipsen BD. Cross-sectional research into people passing away through self-ingesting self-collected lethal medication after receiving demedicalized assistance in suicide. Omega (Westport). 2022;84(4):1100–21. sourceNot checked yet

Probably not a substantial claim. It may state two separate claims as one.

The views and values of patients and families are often overlooked in service planning, leading to programs and services that do not address their needs and preferences.

“The views and values of patients and families are often overlooked in service planning, leading to programs and services that do not address their needs and preferences [39, 40].”

• cites [39] Dirik A, Sandhu S, Giacco D, Barrett K, Bennison G, Collinson S, et al. Why involve families in acute mental healthcare? A collaborative conceptual review. BMJ Open. 2017;7(9):e017680. sourceNot checked yet
• cites [40] Livingston JD, Nijdam-Jones A, Lapsley S, Calderwood C, Brink J. Supporting recovery by improving patient engagement in a forensic mental health hospital: results from a demonstration project. J Am Psychiatr Nurses Assoc. 2013;19(3):132–45. sourceNot checked yet

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

These perspectives support and are supported by prior research calling for MAiD care coordination, inter-professional approaches, and attention to applicants' and families' emotional, social and spiritual needs.

“These perspectives support and are supported by prior research calling for MAiD care coordination, inter-professional approaches, and attention to applicants’ and families’ emotional, social and spiritual needs, among others [24, 25, 50–52].”

• cites [24] Oczkowski SJW, Crawshaw DE, Austin P, Versluis D, Kalles-Chan G, Kekewich M, et al. How can we improve the experiences of patients and families who request medical assistance in Dying? A multi-centre qualitative study. BMC Palliat Care. 2021;20(1):185. sourceNot checked yet
• cites [25] Brown J, Goodridge D, Harrison A, Kemp J, Thorpe L, Weiler R. Care considerations in a patient and family centered medical assistance in dying program. J Palliat Care. 2022;37(3):341–51. sourceNot checked yet
• cites [50] Fujioka JK, Mirza RM, McDonald PL, Klinger CA. Implementation of Medical Assistance in Dying: a scoping review of health care providers’ perspectives. J Pain Symptom Manage. 2018;55(6):1564–76e9. sourceNot checked yet
• cites [51] Crumley ET, Kelly S, Young J, Phinney N, McCarthy J, Gubitz G. How is the medical assistance in dying (MAID) process carried out in Nova Scotia, Canada? A qualitative process model flowchart study. BMJ Open. 2021;11(7):e048698. sourceNot checked yet
• cites [52] Sandman L, Munthe C. Shared decision-making and patient autonomy. Theor Med Bioeth. 2009;30(4):289–310. sourceNot checked yet

Probably not a substantial claim. The paper’s conclusions may not depend on it.

The implications of the study's findings resonate with recent scholarship on 'palliative psychiatry', which focuses on palliative goals of care, such as improving quality of life and relief of suffering, for patients with serious mental illness who are not necessarily at the end of life.

“the implications of our findings resonate with recent scholarship on ‘palliative psychiatry’, which focuses on palliative goals of care, such as improving quality of life and relief of suffering, for patients with serious mental illness who are not necessarily at the end of life [66, 67].”

• cites [66] Trachsel M, Irwin SA, Biller-Andorno N, Hoff P, Riese F. Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits, and risks. BMC Psychiatry. 2016;16(1):260. sourceNot checked yet
• cites [67] Aftab A. What should clinicians Know about Palliative Psychopharmacology? AMA J Ethics. 2023;25(9):E710–7. sourceNot checked yet

Probably not a substantial claim. The paper’s conclusions may not depend on it.

The majority of individuals who received physician assisted death in the Netherlands were diagnosed with depression, personality disorder, or trauma and stress-related disorders.

“Of note, the majority of individuals who received physician assisted death in the Netherlands were diagnosed with depression, personality disorder, or trauma and stress-related disorders [57].”

• cites [57] van Veen S, Widdershoven G, Beekman A, Evans N. Physician assisted death for Psychiatric suffering: experiences in the Netherlands. Front Psychiatry. 2022;13:895387. sourceNot checked yet

Probably not a substantial claim. It may be too vague to check against evidence.

Research on patient and family perspectives on MAiD MI-SUMC implementation and care processes can complement existing and emerging professional practice standards and help inform care delivery.

“Research on patient and family perspectives on MAiD MI-SUMC implementation and care processes can complement existing and emerging professional practice standards and help inform care delivery.”

Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.

The study has limitations, including lack of representation of certain communities, such as Indigenous peoples, LGBTQ2S + participants, immigrants, as well as representation from people with diverse illness trajectories, despite efforts to promote diversity in our sample.

“The study nonetheless has some limitations, including lack of representation of certain communities, such as Indigenous peoples, LGBTQ2S + participants, immigrants, as well as representation from people with diverse illness trajectories, despite efforts to promote diversity in our sample.”

Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds. It may state two separate claims as one.

This study has many strengths, including rigorous qualitative methods, and participatory engagement with experts with lived experience.

“This study has many strengths, including rigorous qualitative methods, and participatory engagement with experts with lived experience.”

Probably not a substantial claim. It may be too vague to check against evidence.

Patient and family perspectives will continue to be essential in MAiD MI-SUMC implementation efforts, to better address the needs of diverse communities and inform MAID MI-SUMC evaluation and improvement efforts.

“Patient and family perspectives will continue to be essential in MAiD MI-SUMC implementation efforts, to better address the needs of diverse communities and inform MAID MI-SUMC evaluation and improvement efforts.”

Probably not a substantial claim. It may state two separate claims as one.

The study took place in a country where MAiD is accepted and legally available for chronic health conditions other than mental illness, and where MAiD MI-SUMC is anticipated to be available in March 2024, thus responses are framed within that presumption.

“Finally, the study took place in a country where MAiD is accepted and legally available for chronic health conditions other than mental illness, and where MAiD MI-SUMC is anticipated to be available in March 2024, thus responses are framed within that presumption.”

• AssumptionRests on an assumption: MAiD MI-SUMC is anticipated to be available in March 2024.

Probably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.

The study amplifies patient and family perspectives on an intervention that remains controversial in the field of psychiatry and adds to the limited research in this important area.

“Nevertheless, the study amplifies patient and family perspectives on an intervention that remains controversial in the field of psychiatry and adds to the limited research in this important area.”

• AssumptionRests on an assumption: MAiD MI-SUMC remains controversial in the field of psychiatry.