Nurse practitioners not always compensated for providing medical assistance in dying

The Nurse Practitioners Association of Ontario says some of its members are helping to provide their patients with medically assisted deaths without compensation.

It wasn't until April of 2017 that nurse practitioners (NPs) in Ontario could prescribe the controlled substances used for medical assistance in dying (MAID).

Since then about 40 NPs across the province have provided either patient assessments or the procedure itself.

A patient must be assessed by two independent health care providers. This can be either a physician or a nurse practitioner. The procedure is the same regardless of who provides it.

One nurse practitioner in Sudbury, Ont. says it's important for her to provide support to patients who want to take this step. She admits that medical assistance in dying is rather limited in Sudbury, in that not a lot of physicians or nurse practitioners are willing to provide it for patients.

CBC agreed to withhold her identity because she fears judgment from colleagues who don't support her position.

"For me, I think what's important is a person's autonomy, their dignity and their own fate. Who am I to judge?," she said.

Over the past year she says she's been involved with between eight to ten cases of MAID, either in Sudbury or nearby. Most of those were in an assessment capacity.

"When a person is diagnosed with a life-limiting illness and they know with a fair degree of certainty that end-of-life is approaching, how they want that to be, I believe, is a patient's choice," she said.

She says two male patients in particular stick in her mind as patients who she felt medical assistance in dying was the right option.

"Their disease was really taking away who they were as a person, their autonomy, their suffering," she said.

"Despite how good palliative care is you can not address that total suffering, particularly the mental and psychological suffering that people go through, as their disease ravages their bodies."

She adds that MAID is a more acceptable in North Bay and Sault Ste. Marie, compared to Sudbury.

"However, it is available...It can be done in community and it can be done in hospital, but there is a process. It is a bit of a cumbersome process," she said.

NPs providing MAID without compensation

Hoda Mankal, with the Nurse Practitioners Association of Ontario, says some of their membership support medical assistance in dying, while others do not.

She says some nurse practitioners are so passionate about helping dying patients that they're providing assistance without compensation.

"This is a service that is up to the request of the client so that doesn't happen in a 9-to-5 workday. A lot of these nurse practitioners are providing this service outside of office hours," Mankal said.

Most nurse practitioners in Ontario are salaried employees. The Ministry of Health and Long Term care does not pay for fee-for-service to them the same way they do for physicians.

"It's when you get into the situation where you're providing these assessments, follow-up or care outside of your clinic or office hours, because nurse practitioners don't bill fee for service so that's when you run into a situation where they are not being compensated," she said.

Not everyone wants to work for free

Willi Kirenko is one of those nurse practitioner who has provided medical assistance in dying on her own time. She is an independent nurse practitioner in Chatham-Kent.

"Some NPs are providing the service during their regular work hours and their employers are covering the cost associated with that work. Others, like myself, are offering it because we can, and we are passionate about improving access."

Kirenko says she's not comfortable revealing the specific number of MAID cases she's been involved with, however she says it's more than 10.

She says medical assistance in dying is something she would want as an option if she is ever in that situation.

"There is a huge trusting relationship between patients and their nurses and nurse practitioners."

Providing support for loved ones afterward

The Sudbury nurse practitioner says the role difference between a nurse practitioner and a physician is that NPs tend to have more time to complete assessments, and are more willing to do more home visits.

She says nurse practitioners also provide support for the family and loved ones afterwards.

"Because when the procedure is completed who is left there for the loved one at home? There isn't a lot of services for the loved ones after the fact," she said.

From June 2016 to the end of December 2017, there were 1,030 medically assisted deaths in Ontario. Nurse practitioners were involved in 131 of those cases as either an assessor or provider.