Table 4 Additional illustrative quotes regarding institutional objection by theme

1. Basis for institutional objection

Religious values

“So all the facilities over the country who claim to not participate – mostly Catholic, some other private ones – do it on the basis of their faith…” (MAiD assessor/provider 24)

“…they were looking at it from the perspective of we are a Jewish hospital and Jewish laws don’t believe in medically assisted death.” (Family caregiver 11)

Philosophy of palliative care

“… our hospice isn’t even a religious organization … and they wanted none of it, and the palliative physicians didn’t want any part of it.” (MAiD assessor/provider 3)

“…it’s a huge barrier. We can’t go into hospice. In fact, hospice tells patients when they’re interviewing them that if they are considering MAID they will not be allowed to come into hospice.” (MAiD assessor/provider 23)

Influence of key stakeholder

“I think it’s completely at the board level. Like all things, governance decides everything institutionally. And I think what’s keeping the governance from accepting it is probably … perceptions around reputation risk.” (MAiD team member 9)

“…[the director] is the one that puts a kibosh on [i.e. puts a stop to] anything remotely concerning MAID … The only inpatient palliative care unit we have … we still have forced transfers, we still have – people aren’t even allowed to be assessed on site. They have to move for both assessments and provision.” (MAiD assessor/provider 1)

“…they’re all funded with public money [faith-based institutions] and the patients and the staff don’t reflect those same values.” (MAiD assessor/provider 24)

2. Scope of refusal

Blanket refusal

“So, the [hospital] today, I went to the parking lot to do the assessment. They won’t let me in the building.” (MAiD assessor/provider 26)

Shift to allow assessments

“I think that’s what they came down to, it’s the act of actually ending a life which is what their religion says you can’t do. Talking about it, finding someone eligible, until you’ve actually ended life you haven’t done something which is against God’s law.” MAiD assessor/provider 6)

“They said they would allow the assessment but not the provision, and then they upheld that. …we did think, especially as a provincially-funded health facility, that they would be required to abide by provincial health laws. But, in fact, religion trumped the law.” (Family caregiver 28)

Other aspects of the MAiD process

Information: “I still think there is an active access issue because providers in that institution are not telling people that it’s an option.” (MAiD assessor/provider 11)

“…who feels empowered to even ask about MAID in a Catholic institution in which they know it’s not allowed? And whose conversation about MAID gets passed the nurse who says “No, we don’t do that here,” or the resident who says “No, we don’t do that here,”? Like the persistence required to even get an assessment or have a conversation with your MRP [Most Responsible Physician] about MAID in a Catholic institution must be enormous, and it is enormous.” (MAiD assessor/provider 15)

IV access: “Some of our nursing agencies won’t even put an IV in for that procedure…” (MAiD assessor/provider 18)

Witnessing: “… we’ve had witnessings where the patients have to leave the hospital and get the forms signed on the sidewalk because they won’t do it inside the hospital.” (Family caregiver 8) (also a volunteer witness for MAiD)

“I have a patient in [rural area] … He had no one to witness his form. He receives homecare on a daily basis, metastatic [cancer]. … a nurse visiting him daily … a palliative care coordinator … a palliative nurse practitioner who’s visiting from [city]. All of them are forbidden by their agencies to witness. … I messaged these people, because they’re all friendly people of mine, and I said ‘Please take this to your supervisor. This is now legal. You are a paid caregiver. You are allowed to sign this legally.’ ‘Oh, no, I’m sorry, it is our policy.’ The [hospital], they have a policy, nobody who’s an employee of the [hospital] is allowed to sign this form. I said ‘You’ve created a barrier now. You’ve added a barrier to the law’…” (MAiD assessor/provider 26)

Discretionary decisions

“They … came up with a thousand and one excuses not to follow the rules and to – they seemed bound and determined to avoid it at all costs. … They were obstructive right until the bitter end.” (Family caregiver 24a)

“… after a year of allowing forms and assessments, they [the hospice] wouldn’t allow him to sign his form on the premises and said he would have to leave the premises. Which is a huge area. It’s a hospital and nursing home and a hospice in one area. So I said to them ‘Are you telling me you want this guy to go in his electric scooter, in the rain and winter, and go a kilometre and a half to leave the property? Which newspaper would you like to talk to?’” (MAiD assessor/provider 24)

“I had another patient transferred to hospice and I got someone on the phone, and they said, ‘We’ll let you in the building.’ ‘Okay, thanks.’ But I’m not sure if that’s a policy thing. They said, ‘We will not provide MAID.’ It’s on their application to the hospice, the patients have to sign that they will not even discuss MAID when they are admitted to a hospice.” (MAiD assessor/provider 26)

“We’ve done very well at working with our institutional conscientious objections. … in some places sometimes they have to be transferred back, but other places, believe it or not, actually will allow us to assess and provide.” (MAiD team member 9)

Locations with little to no problems

“I’m very lucky where we are. The only encounter that I did have was early on when one of our facilities did not have a policy about MAID in place at all one way or the other.” (MAiD assessor/provider 12)

“… I know it happens in other provinces. I know other [specialists] just say “Well, I work in a Catholic place, so I don’t have to do it, like I have never been involved.“ I must say I’ve been to the hospice a few times in Halifax and one of the first times I was there, there was obviously a nurse that was uncomfortable with me being there and I got a bit of a cold shoulder. But that happened once and never again.” (MAiD assessor/provider 2)

3. Lack of transparency regarding institutional position

Lack of transparency regarding institutional position

“They pretended – or they said this was the first time they’d ever faced this situation in the home. So they came up with a thousand and one excuses not to follow the rules and to – they seemed bound and determined to avoid it at all costs.” (Family caregiver 24b)

“She’d been at [institution] for coming on three years. So, basically, as soon as we found out that it was a law now, that we could have that, we started working on that process … So she’d been approved for a little while and then I think she decided that we would give it a couple of months, and in that couple of months we tied up everything … And then we found out that [institution] would not allow her to have the procedure, her provision in her home.” (Family caregiver 28)

“They were unorganised, both in terms of the technical procedures and what you had to go through, but also and more important culturally equipped to deal with it. Their staff didn’t know how to react. They had no protocol of what to tell or not to tell other residents on the floor who knew that something was going on.” (Family caregiver 12)

“On the face of it, it doesn’t seem like that big of an issue. Like, okay, no problem, you don’t allow assessments or assisted deaths, they’ll just go to another spot. But like patients don’t know. They don’t know that these healthcare institutions have those regulations because, at least in [province], they’re not being upfront about it. So a patient just walks into a hospital thinking that it’s a hospital. So then they’re there and now they have to leave, but if they leave then you’re withdrawing them from their care team that they already know and trust … you’re causing pain and suffering on the transfer. … They’re applying for MAID to end their enduring suffering and you’re adding to their enduring suffering by having them leave for the assessment and the death.” (MAiD team member 6)

4. Impacts on patients

Physical pain and other suffering caused by forced transfers

“… they’re still being transferred to a different part of the hospital. … there’s still that stigma that you still have to go to a different part of the hospital. … So it’s not perfect. It’s pretty good, but it’s not perfect.” (MAiD assessor/provider 10)

“…the transfer was very uncomfortable. So, unfortunately that was really bad. To have someone move off of a location where they’ve lived for 10 years in a long-term care facility, that is just ridiculous and hard.” (MAiD assessor/provider 12)

“I had a case where he was in the hospice and he had to be transported out. … to be transported to this place, the poor man had been in so much pain.” (MAiD assessor/provider 17)

Constrained choice

“But where it comes into play for me … is when I’m seeing patients from a palliative care perspective and I ask them what their goals are and they say ‘I want to stay home as long as possible, but if things get too bad I want to have MAID and if things get too bad I want to go to an inpatient setting.’ Well, you can’t have both. You have to make a choice. So if things get too bad and you need to be admitted because your family’s not coping or your symptoms aren’t being managed well enough, then you basically give up MAID. You don’t have to. But the reality is if you’re sick enough to need inpatient care, it’s not going to be to your best interest to then be transferred to [major hospital] to have the procedure done at that point. So again I’ve never dissuaded somebody from making the choice that’s right for them, but they need to be informed and the reaction I get is always, ‘Are you kidding me?’ So it’s disheartening.” (MAiD assessor/provider 1)

“[The patient had been] … languishing for like three weeks after having made a MAID request because they happened to find themselves, by virtue of an ambulance, choosing [a Catholic hospital] over a secular institution. They just happened to find themselves in a place that didn’t affirm their autonomy to make decisions around their end-of-life care. So yeah, it’s unconscionable, it’s bonkers, it’s unjust, it’s nonsensical. It causes distress for patients, it causes distress for clinicians.” (MAiD assessor/provider 15)

Compromised access

“… I might be able to provide for them at this hospital, I’d get emergency privileges to do it, but they wouldn’t have the people around them who had been really caring for them in a very tender and supportive way for a long time. So, I’ve had patients who have then made the decision to just let nature take its course and they missed out on MAID because of that.” (MAiD assessor/provider 5)

“The transfer services aren’t - I mean they’re not made for MAID. We don’t book - we don’t have a system where you arrive at 10:00 and then you pick up the patient. They come when they’re ready. So then that means that families are disconnected from each other in the last hours of the person’s life because the family’s left to go to the new spot but the patient is still waiting over here. We’ve had instances where the patient’s lost capacity because they got too much pain medication on route…” (MAiD team member 6)

Mitigating factors for individual patients

“We have had some patients … where the physician has gone in unbeknownst to the staff, done a MAID assessment and then the patient’s been transferred home to have the procedure.” (MAiD assessor/provider 1)

“She got MAID is what happened, because I like barrelled right through that. Because … the woman asked for MAID. I am her physician. It is my job to make sure she gets it.” (MAiD assessor/provider 14)

“I did do an assessment there. I didn’t ask permission. I just went in as a visitor.” (MAiD assessor/provider 23)

“We were running a secret MAiD operation … Behind their backs.” (Family caregiver 12)

“And the home came up with basically, the same form with their letterhead on top, and said my mum has to fill all of this out. And I put my foot down and said ‘No, absolutely not. This government form is effectively the same thing as your form. You’re welcome to have a photocopy of the government form, otherwise leave us alone.’” (Family caregiver 24a)

5. Impacts on health professionals

Emotional impacts

“I had one patient, they [the staff] went to the media and they went to the police to try to have me arrested.” (MAiD assessor/provider 3)

“…the people on the frontline, the doctors and nurses on the frontline are loving and wonderful people who suffer great moral distress when they have to do this [participate in forced transfers].” (MAiD assessor/provider 17)

“I said, you know, that I would continue to do assessments without any problem, and they threatened me with a College report. And I said ‘Oh, I’ve had lots of talks with the Registrar of the College … we’ve had good, long conversations about this and they do not support your position at all. They believe that doctors should be able to see patients and talk and they don’t support hospital privileging interfering with this.’ So then we made an agreement.” (MAiD assessor/provider 22)

“We [publicly advocated] saying ‘… we are very concerned that there is a lack of knowledge and access for this.’ So I got a death threat.” (MAiD assessor/provider 26)

“That was the longest death I’ve had [due to a complication from the forced transfer and lack of support from the objecting hospital] … when [the patient] finally died and the [family] had left the room, I just collapsed. I started bawling and … - I was trying to be quiet because this is not my grief, right. And I just started weeping and the paramedic came in and was like ‘It’s okay’. It was awful, just awful. I really felt I’d failed [the patient]. You know, I’d described the procedure and ‘it’ll be over in five minutes’. And then for this to happen, an ordeal like that, when if I could have requested [support] of the hospital this could have been avoided.” (MAiD assessor/provider 26)

Impact on professional relationships

“But there has been times where we’ve had to like not go there. Or we’ve had to really just like be battling it. And I knew going into it I was going into a hornet’s nest, and that happened. You know you’re meeting with hostility. No one’s going to help me. No one’s going to help me find what I need. No one’s going to give me the address to put on the death certificate. No one’s going to help me. So, I knew that and I could come prepared to be friendly, to be open, to be – you know, it’s all in the approach, right.” (MAiD assessor/provider 3)

Administrative burdens and lack of remuneration

“They were aware of the law. They were willing to proceed according to the letter of the law. But the palliative care nurse was told while they would not stop her from assisting it wouldn’t be done during her work hours, nor would it be part of her assigned work. She wouldn’t be paid for being there.” (Family caregiver 10)

6. Catalysts for change

Description of changes over time

“…it was very different three years ago than it was now. So I did a lot of first provisions in hospice. They weren’t allowing them in hospice and they weren’t allowing the provision at all, and then they weren’t allowing admissions to do it. Over time it’s better and it’s evolved.” (MAiD assessor/provider 3)

“In the beginning, yes that is definitely the way it was, that there were no assessments or let alone provisions happening in the hospitals.” (MAiD assessor/provider 5)

Positive experiences + normalisation over time

“…the underlying kind of drive comes from the public. It comes from people’s stories and it comes from publication of their stories and sharing of their narratives.” (MAiD team member 5)

“Our laws changed because of patients. The patients challenge the system, change the law. The patients came to the community events that I spoke to. I couldn’t give rounds at the hospital that first month. I asked three or four different departments, can I come and give rounds on MAID. Nobody took me off on it, but I got three invitations in the community. Patients wanted to know. Patients took my information, went to their doctor’s office and said, hey, this exists, you don’t know about it, you find out about it, buddy, because I want – patients drive this change, and I think – and I watched it happen. Patients drove the change in the palliative care communities that were amenable to it. I know, several palliative care doctors that said, I respect what you do, I respect my patient’s choice, this is not something I’m going to ever do. A year later that doctor did an assessment for me. So it’s patient driven.” (MAiD assessor/provider 8)

“I think they’ve come to some understanding that this is something that people who are Catholic wish to have, and it’s part of their healthcare, and they do recognise that it’s a legal right.” (MAiD team member 11)

Advocacy in response to negative impacts on patients

“… we vocally fought … and got the local press onside. We had a campaign. … [the institutions] wouldn’t have just dropped them [the restrictions] if we hadn’t fought that.” (MAiD assessor/provider 6)

Education and relationship building

“But I think the upfront work that the health authority did - so I have to say the [health authority] did a really good job of doing a lot of background institutional work and meeting with the nurses, the nurse practitioners, the long-term care workers. I mean very early on we had an educational session for all the physicians who worked in long-term care who were itinerant, you know who work in like three or four of the facilities, of saying ‘Here’s people who might be interested in this. Here’s what it looks like,’ and meeting with the nurses and social workers and care aides. Then with pretty well every institutional one that I did, even though we didn’t have the religious objective, I mean I sat down probably in about seven different long-term care facilities with the staff and said ‘Okay, well, Mrs Smith’ or Mrs Jones or whoever it is ‘has just died. Does anyone have any questions about how that process rolls out? How’s everyone feeling about it?’ You know, it’s difficult when they’re trying so hard to make that person’s life bearable and then they all of a sudden die. It’s like, no, you didn’t fail. It’s just that this person really had come to the end of their rope and they wanted to take some control back. So that was helpful. Because, unfortunately, a lot of the care workers worldwide are Filipino and Christian, right. I think in every single western, English-speaking country this is the reality. That’s hard for someone whose Christian values and sense of caring and duty are very, very strong. And I think it’s really worthwhile investing that time in the care workers.” (MAiD assessor/provider 12)

“… a lot of that [allowing assessments on site] can be attributed to [team lead name] and our team, really. Because they worked super hard just making sure that there was education around what we were trying to do, education around responsibilities for objection, around transfer of care and what they mean to a critically ill, dying patient. So, I think that [team lead name] needs to be credited with all of that … [they] moved this along single-handedly.” (MAiD team member 1)

Institutional dynamics

“…the medical director, family doctor, palliative care doctor, and she told me they were the first hospice in the country to have a policy … She wrote the policy, so it was her initiative. She was not – that was not a requirement. I think it would be true of all the private facilities, long term care facilities, I doubt any of them have policies on medical assistance in dying.” (MAiD assessor/provider 11)

Regulatory mechanisms and leadership

“I would say it’s gotten a lot better. So it does sometimes come down to the directors and the medical leads, but I think that they have had a clear message from the health authority and from the province. It’s different if you are a member of the [British Columbia] Master Denominational Health Agreement, but if you are not and you are a publicly-funded facility then you do not have a legitimate argument to not support a resident who lives in your facility if they – you know, you are then blocking access to care.” (MAiD team member 5)

“We said right at the outset that access to MAID was a Charter right for Canadian citizens and we were a public body. And, therefore, we would have no part of any of our facilities where MAID would not be permitted. It would happen where the patients are. We would have no death destinations and we’d have no opt out sites. So that got me a bit of heat early on… It turned out that was very much the best decision that we made right at the beginning because it set the atmosphere for the whole thing. We spent a lot of time educating.” (MAiD team member 8)

“…there are some champions within the health authority… [who] really pushed it ahead. We thought it was going to go to a court battle and it didn’t, the health authority worked it out.” (MAiD assessor/provider 10)

“…the health authority worked really hard to understand what they [the Catholic institution] wanted.” (MAiD team member 11)