18Charting New Territory: Reflections on Accompanying a Client who has Chosen Medical Assistance in Dying (MAiD)

Kimberly A. Thomas, Ivana Djuraskovic

This chapter provides two reflections related to an ethical dilemma involving medical assistance in dying (MAiD). The first reflection describes the journey that a provisional psychologist (Kim) underwent in deciding to support her client, John (a pseudonym), in pursuing MAiD and by being present at the time of his death. Kim deconstructs her ethical decision-making process regarding John’s wish to have her present at his death. She also discusses the roots of her reflection, obstacles she encountered in making her decision to be with John when he passed away, and tips for clinicians dealing with difficult ethical dilemmas. The second reflection describes her supervisor’s (Ivana’s) experience in helping Kim to make a decision that was in John’s best interests. The chapter ends with a postscript from both authors, offering thoughts about their journey and honouring John’s memory.

Kim’s Reflection: A Provisional Psychologist’s Tale

My eyes and ears were opened when I saw, heard, and felt the plight of a terminally ill individual in pursuit of MAiD. I did not expect to embark on such a therapeutic journey in my career as a psychologist, let alone encounter it in the first several months of my placement as a provisional psychologist providing therapy in a community health clinic that served some of my city’s most vulnerable populations. Many of those served are survivors of pervasive and systemic trauma spanning the course of their lifetime. Their struggles often are rooted in historically unmet needs to be seen, heard, and believed by those who are tasked to provide care and protection, namely, social and health service providers. These providers are also tasked with promoting and protecting client autonomy, self-determination, and choice in their clients’ wellness journey. This includes securing dignified and humane care throughout their lives, including the dying experience.

Part of this chapter speaks to the reflections and ethical challenges I encountered as both a clinician and a human being working alongside a client on his journey of choosing and planning for his death through MAiD. MAiD refers to “what is commonly called voluntary euthanasia (i.e., the administration by a medical practitioner or nurse practitioner of medication that will cause a person’s death at their request) and assisted suicide (i.e., the prescription or provision by a medical practitioner or nurse practitioner of medication that a person could self-administer to cause their own death)” (Government of Canada Department of Justice, 2018). I also include tips and learnings that I hope others may find useful as a source for reflection and consideration. Through this experience, I came to realize first-hand some of the challenges clients and clinicians may face in navigating a client’s choice of MAiD—a choice that is becoming more frequent in our society. The experience opened my eyes to the need for the discipline of psychology to acknowledge the unique position it holds in the lives of vulnerable clients, especially when invited to be part of their dying experience.

The Roots of My Reflection

Upon completion of my master’s degree, I accepted a job placement at a community health clinic. The physician who referred John to me informed me that working with him might be challenging given that John did not trust clinicians. Many survivors of complex trauma report invalidating experiences within the health care system. I understood and sympathized with his distrust and let the physician know I was up for the challenge. I readily welcomed John into my practice for what would turn out to be an unexpectedly life-changing journey.

When we started treatment, John let me know that he was pursuing MAiD for when his body could no longer support his quality of life. As such, the narratives of life and death were common guests in our sessions. I also came to learn that John was estranged from all members of his family, and that he had no friends who he considered able to provide safe emotional supports for him. John shared with me the complicated nature of his relational past and said that there were many wounds he did not expect to be healed in his lifetime. In the two years we worked together, there were many ruptures and repairs relating to his mistrust of the medical system, and a fair amount of waxing and waning regarding being able to step two feet into the therapeutic relationship with me—in part, no doubt, due to his relational trauma history. Furthermore, though John was committed to pursuing MAiD, securing this was never a sure thing as there were medical practitioners along the way who had raised questions about his psychological fitness to make such a choice. These challenges could have been barriers to his securing MAiD, yet John’s fight compelled him to move forward to pursue his right to a dignified death through MAiD. Amid all the hurdles and hoops, I invited John to keep returning to the therapeutic process with me. In his own time, every time, he came back—something that humbles me to this day.

Seasons passed and his body continued to deteriorate. The cruel course of his health diagnoses was unrelenting, and his body became increasingly weak. John and his treatment team had navigated the challenging process of securing MAiD in the next few months. Eventually, he called me to say he could no longer get himself on transportation safely due to the deterioration in his body. He said he was ready to have me come to meet him at home. I recall how hard it was for him to accept my previous offers to meet with him in his home. Where we once walked the halls of the community clinic together, we found ourselves sitting in his living room or taking a couple steps onto the patio. We spent the last several months of sessions in the safe place of his home, where he would play rock and roll on the stereo, all the while playing air guitar. He set out a pair of slippers for me by the door to use every week I visited and greeted me with a smile time and time again.

One day as he sat across from me on the sofa, his demeanour changed. He appeared nervous as he let me know he had something important he wanted to ask me. In that moment, my heart jumped into my throat as I knew what he was going to say. The words came out and felt suspended in the air for a moment: “Would you be there to hold my hand as I die, Kim?” Immediately, I heard an internal voice that spoke with clarity and a sense of knowing “Yes, I would be honoured. I am here with you every step of the way.” However, I did not say it out loud. I paused.

Finding My Compass: Reliance on The Discipline and Self-Reflection

When confronted with the ethical dilemma of whether to accept John’s request to be present at his time of death, I was a neophyte provisional psychologist. I can recall that the moment he asked me to be with him during his passage through death, the weight of his request struck me deeply in my human heart, yet it also kindled immediate uncertainty in my clinical brain. I felt both honoured and speechless. My heart yearned to say yes. It felt profound that John had lived his life feeling abandoned and, at times, choosing to be alone in the belief that this could keep him safe. However, he had stepped bravely into trust and a sense of attachment with me. It seemed unimaginable that he could be denied the ability to leave this world with his chosen support person. I was jarred out of this emotional reflection by the rational thoughts that reminded me this was a request I did not have an answer for at this time. I never had been asked this by a client, nor had I ever read or heard of any clinician being asked. I did not know what my ethical obligations were.

At the time John first asked me, I validated his immense courage in making his needs known. I also reflected what a great honour and privilege it was to be asked. In this moment of John’s vulnerability, I looked at him and admitted that because I cared for him, and because my role was to ensure my decisions are in the service of enhancing benefit and decreasing harm, I would have to engage in consultation and personal reflection before I could come to an answer.

During this moment, I could sense my not answering him fed into his uncertainty regarding the medical system and his hope to have my support throughout his MAiD journey. However, he told me he respected my commitment to navigate this uncharted territory. He was tongue-in-cheek in his response, winking as he told me, “Just don’t take too long deciding.” Hearing him say this struck me like a ton of bricks. The gravity of the sentiment was palpable—John’s life was to end whether I accepted his invitation or not. I felt relief for him, and sadness that our journey was to close so very soon.

As a provisional psychologist, I was used to asking questions—lots of questions—of my supervisors, interdisciplinary colleagues, and mental health peers. My first point of contact was to my compass, my provisional supervisor, Dr. Ivana Djuraskovic. I vividly recall her reflecting to me that she was not surprised John asked me to be present, given his life circumstances and the therapeutic alliance she had witnessed us build. In supervision, she had supported my work with John over the previous two years and knew how hard-fought this relationship was for both him and me. John’s ability to connect with me after having survived so much wounding and suffering within relationships was humbling. Yet, at that time, it also meant I was the sole support person in his life, and he had asked me to be present at his death.

Ivana too reflected uncertainty regarding precedent for this type of request. She encouraged me to start out by consulting with the professional guidance department of the College of Alberta Psychologists and let me know she would be seeking consultation from the discipline as well. I felt a sense of duty to commit to an ethical course of exploration, both to minimize possible harm to John and to ensure I was protected professionally. I felt my humanity and my role as a provisional psychologist hung in the balance. This was an anxious space to hold for some time. Having Ivana in my corner providing supportive supervision filled me with a sense of reassurance. We were in this together, and we were both committed to ethical decision making and personal reflective practice. Without competent supervision, I am not confident that continuous due diligence could be upheld—the risk of harm to John and me could have been great.

When I proceeded to call the College of Alberta Psychologists (CAP), I was prepared not to be handed an explicit road map for navigating this dilemma due to the intersection of personal and professional factors impacting any one professional. However, what I was not expecting was for the consulting members to tell me that they had never received this ethical dilemma before. I engaged in separate consultations with two members of the professional guidance department and was reminded that the CAP guidelines do not provide explicit dos and don’ts for psychologist’s involvement in MAiD. Rather, I was encouraged to reflect on how to say yes or no to John’s request in a manner consistent with the Canadian Code of Ethics for Psychologists (Canadian Psychological Association [CPA], 2017).

My fear increased upon receiving this feedback. Though reliance on the discipline was my starting point, this ethical decision-making process taught me that ultimately it is also my own process of critical reflection that I must come to trust. This ethical dilemma had me reflect that my neophyte position led me to seek reassurance and answers from consultation. However, the result of these discussions was also encouragement for me to engage in a process of critical self-reflection, and in doing so, find my own inner compass and nurture a deeper trust in myself. Consulting with the professional guidance department and my provisional supervisor also compelled me to reflect on my acceptance of the art and science of ethical decision making—sitting with the uncomfortable reality that there is no formulaic answer to many of the dilemmas we will come to face in this work.

Pathfinding: Forks in the Road

In having identified both reliance on the discipline and my personal conscience as parts of the compass guiding me through my ethical decision-making process, I considered John’s moral right to request my presence at the time of his death. Informed from a palliative care perspective, I believe that end-of-life and bereavement care is a human right. Therefore, I knew that I needed to endeavour to support John in his self-knowledge, agency, and decision-making process to control his death experience. John’s vulnerability (economic, lack of social supports) and the Code’s value of Protection for vulnerable persons were also of significant considerations. John had limited options to access other counselling services or social supports for his MAiD procedure. I informed him of alternative palliative counselling supports should he be interested. However, after some communication with such possible service providers, he decided against pursuing these options.

Given John’s hope that I be present, I invited him to consider possible risks of my being in the room, and whether we would be able to troubleshoot safety planning if I had to leave the room. John said he would respect whatever decision I made about being with him. I felt the weight of this responsibility in my gut—there would be no opportunity for do-overs or rupture repairs. My presence or lack thereof would be part of his final passage. Involving him in the ethical decision-making process was the most important thing I did in my clinical journey with him. John reflected that inviting him to be an active participant in the process gave him choice regarding ongoing consent, and voice in directing his dying process. This contributed to his sense of dignity. This time, the medical system was not doing things to him, or leaving him to feel abandoned and alone. His voice mattered.

I also considered the problems of possibly establishing a dual relationship and invited John to discuss his rationale for my being present for the MAiD procedure. He stated that his request was twofold—for me to be present both as his therapist and his support person. Through consultation with two members of the CAP Professional Guidance Committee, my provisional supervisor, CAP members and colleagues, I came to the decision that to be present both as his support person and therapist would be complementary and inseparable in the situation and, thus, not conflicting in nature.

People I have known and loved have died alone. My experience of this spurred a deep sense of wanting to accept John’s request of me, so that he too did not have to die in isolation. However, the anxious part of me was nervous given the gravity of his request and the realization that the intersection of MAiD and the role of psychologists throughout the process was a relatively new topic.

Building upon my reflective process, I brought my insights of possible personal biases, stressors, and self-interest to ongoing consultation and supervision with members of the discipline of psychology, as well as consultation with members of other disciplines. For example, I consulted with John’s physician of record regarding what I could expect if I were present for a MAiD procedure. I also received ongoing consultation with my fellow mental health colleagues at my community health clinic, presenting my ethical decision-making process as part of case conferences and clinical rounds to panels of psychologists and social workers. This process highlighted the duty I have to look after my needs, especially given my work with clients with trauma histories navigating the end of their lives. To supplement my self-care activities, I took it upon myself to attend formal counselling with a grief/palliative therapist as I navigated this ethical dilemma. Placing importance upon myself as the clinician reminded me that, as therapists, we sweep the path for our clients along their journeys.

The Forest Through the Trees: Forging a Route Forward

Navigating my way through this ethical dilemma elucidated for me the need for our discipline to create signposts for those who may find themselves working with clients journeying through the MAiD process. Prior to John’s death, he relayed his hope for a future in which psychologists would be more active participants for clients pursuing MAiD. He spoke of how his work with me had brought about a sense of feeling seen, heard, understood, and validated in his determination to live with dignity no matter how much he struggled. He shared with me how having a therapist working with him through his MAiD process fostered generativity and a belief that his legacy would have meaning. He spoke about how our work helped him uncover the strength and wisdom within himself to “know the great things I have done and how successful I was every day; which I do not think I would have got to without having the reflection opportunities with you.” What was most profound for me was his reflection on my eventual decision to accept his request for me to be present during his death. He stated, “You reached out to me. You came and found me time and time again—nobody ever came looking for me or stayed with me in my life. Thank you for finding me, for holding on—you did not let me go.”

John lamented that although waiting for my answer was challenging, he hoped that his request and my decision-making process could help encourage open dialogue in the field of psychology regarding considerations of MAiD for our clients, our discipline, and ourselves as clinicians. Taken in concert with the feedback from the College that I was the first person to present the dilemma of being asked to be present during a client’s MAiD procedure has motivated me to advocate for much more interdisciplinary discussion, consultation, research, conference engagement, and the writing of reflective pieces regarding client experiences as they journey through MAiD, as well as clinician experiences as they help to navigate that journey.

Upon reflecting now, I could not feel more privileged and grateful for the opportunity to be with John in his final moments. John’s request changed me both as a person and as a clinician, and I would not take back any of the process. The anxieties, the second-guessing myself, the discomfort with not having a straightforward answer, the what-ifs, the facing of my personal biases, the painful process of turning inwards and of looking outwards to receive critical feedback, and the tears of frustration, joy, and gratitude for the help and collegiality of others who supported me—these experiences revealed to me much about the art and science of ethical decision-making and contributed to the human being and clinician I am today.

Ivana’s Reflection: A Supervisor’s Tale

I still remember it clearly. I was in the living room sitting on my couch when the telephone rang. It was late afternoon, and I was in no mood for a conversation. However, when I saw Kim’s number on the telephone display, I knew that it was something important. Kim never calls out of the blue unless it is important. I answered, and I heard Kim’s voice say, “John wants me to be by his bedside when he dies.” Initially, I did not say anything. I just released a long sigh. Frankly, I did not know what to say. John had been Kim’s client for quite some time, and I was very familiar with his situation. I had never met John personally, but I knew his story. In my mind, he was someone who was set in his ways. It is true that he was struggling with mental health concerns. However, most of all, he was struggling with debilitating illness and he was sure that when his body started to fail him, he wanted to die on his own terms, on the date he chose, with people he chose to be by his side. I related to John’s struggle with physical illness, and I have said on more than one occasion that I would make the same decision if I were in his shoes—to die on my own terms. However, in this particular situation, I did not know how to respond to Kim’s statement that John wanted her with him when he died. In situations that have no clear answer, I always become curious. I invited Kim to tell me more. She gave me a quick rundown of the most recent experiences she had with John and informed me that John had picked a date on which he would die, and it was coming soon. My initial gut reaction was “I don’t think it is within your scope of practice to sit with John while he is exiting this world. You are his psychologist. You have worked with him. You processed his thoughts and feelings, and now is probably a good time to start closing your work with him.” I knew instinctively that what I was saying to Kim was coming from fear and not from an informed place. As I was laying out all the reasons why I thought that Kim should not attend John’s death, I kept hearing myself somewhere in the background, saying, “Come on Ivana! You did not consider all the factors at play here. What you are really telling Kim right now is that you do not want to bother with another complicated situation, and that you are afraid. But you are her supervisor and the least you could do is support her in figuring out the best thing to do for John and for her. This is your job, whether you like it or not. Besides, you love complex situations.” In response to that inner voice, I said, “Ok mind, I will step back and start again.”

At the time, medically assisted dying was relatively new across Canada, including Alberta. Up until John, I had never met or known anybody either personally or professionally who wanted to die through MAiD. I had heard about an occasional circumstance that made the news, but it was not in my backyard, so I did not pay attention. At least, not until Kim called me and told me that John requested her to be present at his MAiD. After some pondering, and conversing back and forth, I still stood by my decision and told Kim that it was likely not her job to be by John’s side during his last moments. I rationalized that being there would represent a role confusion and dual relationship, and possibly cause harm to John and Kim, respectively. Kim understood my reasoning; however, she still noted that she could not quite see why the mere act of holding John’s hand while he was exiting this world was so problematic. She provided all the reasons why being with John in his last moments would be the most appropriate decision. She talked about John’s social isolation, the depth of their therapeutic relationship, and John’s willingness to present his wishes to Kim and share the written notes and journals he kept over the years. John kept detailed notes of his process of deciding to die through MAiD, including reasons why it would be relevant for his psychologist to be present at his death. He was a loner type of person. He did not have many friends, and his family did not want to have any contact with him. John was also extremely intelligent and set in his ways. He knew the gravity of the question he had posed to Kim, but he also knew the reasons why he wanted Kim to be part of his death journey. He felt that Kim could support him, and he also felt that Kim could tell his story. John wanted his story to be heard because he did not want to be just a statistic. He wanted the world to know that there is beauty and dignity in making such a decision. In all reality, John was a difficult individual, with a complex mind and needs; yet being willing to connect to one random psychologist allowed him to find self-compassion, self-confidence, and willingness to live his journey in an authentic way. John felt that it was his responsibility to pave the way for other clients who felt the lack of voice in their own lives. John had experienced many obstacles in having his decision finalized. On his journey, he met with professionals who did not support his decision to die through MAiD and who questioned his ability to make an informed decision to die. In the process, John even underwent a psychiatric assessment, the results of which put his wish to die in question.

Kim and I did not make a definitive decision at the end of our first conversation. I was not sure whether she should be present during John’s passing or not. And Kim was worried she would abandon John if she decided to not attend his MAiD. Like I always do when a situation is not an emergency, I asked Kim to take a break, sleep on it, and review the ethical decision-making model. We scheduled another conversation, and I promised her that I would consult with a couple of senior colleagues to pick their brains about this medically assisted dying process. That night I could not sleep. I tossed and turned and kept asking myself “What would John want me to do?” Then again, I knew that what clients may think is best for them is sometimes not the best for them. “How did I get myself in this mess? How is it that these complicated situations end up in my backyard? Why?” My mind kept running its commentary until the wee morning hours; yet, when sun came out, I still did not have any answers. I rose slowly, my body aching, and my head pounding. And then I called my former supervisor and asked him what he thought about John’s situation. My hope was that he would perhaps support my decision of saying no. However, he did not do that. He simply asked me a question: “If we do not honour such important client wishes, are we abandoning them?” Well, that was indeed a question to ponder. Are we abandoning our clients? Are we contributing to a larger systemic barrier when it comes to people freely choosing MAiD? I called Kim later that day and said, “I am more confused now than yesterday, and I do not know what the best answer is, but today I am no longer prepared to say no. I think we need to explore this more.” I sensed a relief in Kim’s voice when she noted that she shared my thoughts. We agreed that the best way to go about this is to work through the ethical decision-making model in the Canadian Code of Ethics for Psychologists (2017) and see what decisions could come from that. I also suggested that Kim consult with the College of Alberta Psychologists and explore possible courses of action for her and John with its Professional Guidance Committee.

Deciding to work through the ethical decision-making model was just the beginning of a much more complex journey for both Kim and me. In theory, it seems simple enough just to follow the model and make a decision. However, in this circumstance, no decision was straightforward or easy. I wondered about many things as I considered the ethical decision-making steps. I wondered about John’s family. Did they know what he was planning? How would they be affected? How would the event of John’s passing affect Kim? What does it really mean to be a party to someone’s death? I worried increasingly about John and whether he would feel completely abandoned if Kim said no to his request. I also worried about Kim because a couple of years earlier, she had experienced a grief and loss that could be triggered by simply attending John’s passing. Would she have any support to help her process her thoughts and feelings? How would I support her adequately? I had so many questions that I thought my brain would burst. I had been in practice long enough to know that the ethical dilemma Kim and I faced was not easy. We were constrained by time limits and needed to decide sooner rather than later whether Kim would be present at John’s passing. We also had to consider how Kim would deliver her decision to John and still be consistent with the Canadian Code of Ethics for Psychologists and the College of Alberta Psychologists Standards of Practice. I quickly learned that the decision that Kim and I had to make involved our personal conscience, especially when the code of ethics and standards of practice did not give clear answers when applied to John’s situation.

Kim and I frequently discussed the multiple contexts that were relevant to John’s life. In making our decision, we had to consider the level of personal support that was available to him. That was a clear but tough consideration. John noted often that he was somewhat of a social recluse, and that he did not maintain relationships with family and friends. He said he was estranged from his primary family, including his son, and that he did not want any of his family present at his passing. John said he saw Kim’s presence at his passing as complementary and not in any way conflicting with anyone else’s role. In fact, we realized that, due to his social isolation, Kim’s presence at his passing could be a catalyst for, rather than a hindrance to, a healthy transition into death. John’s wishes for Kim to be present at his passing involved his belief that Kim was a trusted, compassionate, and empathetic person and psychologist. From his perspective, Kim bore witness to his journey and his fight to gain the right to decide when to die. She understood his traumas and was aware that he often described her “as the only person who ever really looked out for me.” John also seemed prepared to accept Kim’s potential decision not to be present at his passing, noting that “I have died alone once, I can do it again.” John was referring to the experience he had when he died, but after several minutes of life-saving interventions regained consciousness. He had reflected on how lonely and difficult this experience was for him. Could Kim and I live with ourselves if we left John to die alone? This was the question that stretched us beyond the moral constraints of this circumstance.

It soon became clear to me that if Kim decided not to be present at John’s passing, she would in a way be abdicating her responsibility towards him. Nevertheless, was that enough to say yes to John’s request? I conversed frequently with Kim about the meaning of her decision-making process and how she would be able to justify it if asked. Kim always stood her ground and said that she would document every step in detail, and that she would consider the ethical decision-making model carefully. She also mentioned the bigger value questions in psychology; for instance, what service do we provide to our clients if we decline their wishes without due consideration? I always respected Kim’s concern and love for all human beings. I had never seen her be judgemental, and her empathy for clients was “a dance in the making.” In the past, when I observed Kim’s sessions, I often found myself longing to be as non-judgemental as she is. However, concerning John’s situation, I was not yet fully convinced that by saying yes to his request, we were making a right decision. As a supervisor, I wanted to make sure that Kim was not engaging in something that was outside of her competence.

In one of our conversations, I asked Kim whether she felt she had enough competence to support John in his transition from life to death. She was really honest and told me, “Well I never have sat with someone during their last moments. However, I have counselled clients who were in palliative care. So, I think I know enough about what to expect.” She also said something that affected me deeply. She noted that when involved in continuity-of-care activities, psychologists often need to advocate for clients. She felt strongly about this advocacy and reiterated many times that if we are to put social justice into practice, such advocacy would be a responsibility. For example, at John’s request, Kim worked closely with John’s physician of record, who was also the practitioner John chose to complete his MAiD procedure, and attended many appointments with John to provide emotional and psychological support as he navigated the steps of the MAiD assessment process. John informed Kim that, with someone whom he trusted to journey alongside him, he felt less alone in the process.

Kim also advocated for John’s choice to explore the possibility of having her be present to hold his hand when he died. She took the additional step of consulting with two senior counselling psychology supervisors. Both supported her decision about not abandoning John, advocating for him, and providing care in the last moments of his life. For Kim, a decision to be present at John’s passing was not philosophical or moral. It was human. She often mentioned that the first thing that came to mind whenever she thought about her decision was the ethical principle of Respect for the Dignity of Persons and Peoples. From Kim’s perspective as a psychologist, she felt that her professional judgement was of the outmost importance given the complexity of John’s situation. Kim did not in any way direct or impact John’s decision to engage in medically assisted dying, and she knew she was not obligated to be with him at the time of his death. However, she understood the meaning of the process of informed consent and engaged in conversations with John regularly to explore his decision to die through MAiD. As we moved through the process of solving the ethical dilemma, Kim and I recognized John’s right to self-determination and personal liberty to make his own decisions. As we came closer to saying yes to John’s request to have Kim present at his passing, we began wondering about how the process should evolve to protect both John and Kim. We had to consider how vulnerable John felt within the mental health system, the multiple oppressions he experienced over the years, and the difficulty he had in exercising his right to engage in medically assisted dying. John had been in the mental health system for a long time, and he had come across counsellors and physicians who did not understand either his emotional or physical pain. Many did not want to entertain the idea that a person like him could make a valid decision to die at their own volition.

Through a careful and detailed process of ethical decision-making, Kim and I learned important lessons. Initially, it was intimidating even to think that psychologists could be present at their clients’ last moments. After all, we work in a profession where our work often consists of keeping our clients alive. However, in John’s situation, being able to have Kim at his passing was giving him his life back in a way. He was able to exit his world of suffering and pain with someone at his side whom he trusted and knew would support him as he was taking his last breath. For Kim, I think the process was both painful and rewarding because she had advocated for John and understood him in the way he needed to be understood. Many people participated in our decision making. In the process, we consulted with at least ten professionals about whether Kim should be present at John’s passing or not. The most beautiful outcome was that all of us agreed that saying no would have had far more negative consequences than positive ones.

Postscript

John chose to pass away on his birthday. He decided to have his favourite meal, a view towards the mountains, and music playing in the background. He had been able to tie up loose ends with one of his family members whom John decided to invite to his passing after all. This family member accepted his invitation to be present and sat on the edge of his bed. John also asked for his physician’s dog to be present to lay at his feet. He had Kim by his side holding his hand. We had a telephone conversation shortly after John passed away. When Ivana asked Kim how she felt, Kim replied “It was beautiful, Ivana. It was a celebration of life and choice. As John exited this world, I even thought I heard him giggle in the background . . . and he said he was sorry he did not get to meet you.” Kim and Ivana also discussed at length Kim’s self-care plan and how she would be kind to herself in the days following John’s death.

John impacted us in significant ways. He fought for his right to freely choose to die with the assistance of MAiD, and how important such freedom can be in a person’s life. We think about him often and imagine that John’s spirit lingers in our lives. Occasionally, we are reminded how challenging and difficult, but rewarding and meaningful our work really is. We learned that supervision is not always straightforward and that supervisors need to remember they still do work behind the curtains. Supervisors’ decisions impact students’ clients. In addition, students come to supervisors for guidance and support and expect them to share their wisdom. Supervisors and students both need to recognize their fears and discomfort with certain situations and need to open up space for that discomfort. When we can sit with that discomfort, we are more able to make sound ethical decisions.

We reminisce about John often when we see each other. We imagine he is still there somewhere to guide us in decisions to come, and we are grateful to him for deepening our understanding of ethics. Fly freely John! You deserve it. And thank you.

Questions for Reflection

1. Identify some of the beliefs and biases you have about MAiD. How might they influence your work with clients considering MAiD?
2. What role do you think the following would play in developing your competencies related to MAiD? Knowledge of relevant legislation? Knowledge of practice guidelines (e.g., CPA MAiD Task Force Report & Practice Guidelines for Psychologist Involved in End-of-Life Decisions)? Consultation? Supervision? Formal training?
3. Imagine you decide to seek MAiD for yourself. What thoughts and feelings might you experience? What kind of psychological support would you want to have?
4. Your client requests your presence at the time of their death through MAiD. The client’s daughter asks you not to be present, as she considers it to be their family’s private journey. Using the CPA ethical decision-making model as a framework, what do you think would be the best course of action?

References

Canadian Psychological Association. (2017). Canadian code of ethics for psychologists (4th ed.). https://cpa.ca/docs/File/Ethics/CPA_Code_2017_4thEd.pdf

Canadian Psychological Association. (2020). MAiD task force report & practice guidelines for psychologists involved in end-of-life decisions. https://cpa.ca/docs/File/Task_Forces/Practice_Guidelines_End_of_Life_Decisions_CPATaskforceReport_BoardApproved_March12020.pdf

Government of Canada Department of Justice. (2018, September 14). Legislative background: Medical assistance in dying (Bill C-14, as assented to on June 17, 2016). https://justice.gc.ca/eng/rp-pr/other-autre/adra-amsr/p2.