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Nursing Practice and Assisted Death

Nursing Practice and Assisted Death

February 2015

On February 06, 2015 the Supreme Court of Canada 'struck down' the Criminal Code provisions that prohibited physician-assisted death (more popularly known as physician-assisted suicide). The Court ruled that grievously ill patients have a legal right to assistance with the termination of their life.

On February 06, 2015 the Supreme Court of Canada 'struck down' the Criminal Code provisions that prohibited physician-assisted death (more popularly known as physician-assisted suicide). The Court ruled that grievously ill patients have a legal right to assistance with the termination of their life. The ruling is as follows:

Section 241(b) and s. 14 of the Criminal Code unjustifiably infringe s. 7 of the Charter and are of no force or effect to the extent that they prohibit physician-assisted death for a competent adult person who (1) clearly consents to the termination of life and (2) has a grievous irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.

This virtual discussion is intended to open debate and dialogue about the implications of this monumental decision on nursing practice in New Brunswick. The federal and provincial governments have one-year to develop new legislation that respects this right. The implications for nurses in New Brunswick (and the rest of the country) are profound.

We propose to have a debate and discussion about the implications of this decision on nursing practice in New Brunswick. The following questions are intended to stimulate dialogue:

  1. What would be the standard for determining that a particular patient is competent enough to consent to the termination of his or her life; that he or she has a ‘grievous irremediable medical condition;’ or that the patient is enduring intolerable suffering?
  2. Under what conditions could a nurse be forced to, or refuse to, participate in assisted death?
  3. When, where, and how should nurses have discussions about assisted death with patients?

I look forward to hearing your thoughts.

References:


Presenter

Dr Timothy Christie

Dr Timothy Christie, BA (hons), MA, MHSc, PhD

Regional Director of Ethics Services for Horizon Health Network

Archived Comments

Anonymous

I believe that healthcare professionals can greatly influence a patients choice and for that reason we need to be cognisant of that ''power'' that we hold and not let our own values, whether we are for or against this ruling, influence how we support patients who will choose this route. This decision will ultimately be the one of the patient and I believe it needs to be that way. Part of ''caring'' for a patient involves respecting their decisions and rights and I am sure that NB RNs will competently and professionally support patients in their choices.

Anonymous

Determining competency should not be any different than the requirements are at the present time. What is critical is a full explanation of the situation with the client AND their family with some opportunity for discussion. I don't mean the Doc leaning on the doorframe and asking what they think, I mean taking time to sit down with the client to discuss the whole situation with ample opportunity for them to ask questions and reflect on the ramifications. In terms of the difference between irremediable medical condition or patient enduring intolerable suffering that is not for us to decide but for the client to determine if they feel there is little point to continuing in the state that they are in. Nurses' should be prepared to follow-up with some of these very difficult and sensitive situations. They should be there to continue to answer questions, support the client in asking the questions, and support them in whatever their final decision is. We have no right to place barriers between the client and their wishes. As with many contentious situations, nurses who are morally or ethically opposed to being a part of this situation should simply remove themselves from the situation because their opposition will be communicated through body language, and tone to the client and the last thing that they need at that time is to be, or feel that they are, being judged by someone else's standards. This subject will required ongoing discussion and thought, but thank goodness we can at least have the conversation and offer this solution to those clients who see it as one viable option.

Anonymous

I believe that the standard for determination will need to involve more than one health care professional. There is many "tools" available to assist with screening of competency however, the determination will need to be made after consultation with a team approach upon diagnosis of a incurable, deteroriating condition in that the patient is seeking assisted death. It will ulimately need to be the patient who decides if their suffering is "intolerable." That will need to be kept subjective. We often, as health care providers, assume we know what a client is experiencing when in fact, we do not and nor should we assume we do. We always refer to "patient centered care" but more often than not we are providing "provider centered care." I believe the discussion around assisted death will be one that will need to happen after a therapeutic relationship is formed. I do not believe that this should be done in the face of an exeracerbation or acute event often. I think the bulk of these conversations need to take place upon diagnosis of the disease/diability. As far as the nurse's rights to refuse to assist or participate in the assisted death, I believe it will need to fall to the individual nurses to examine their core values. I believe our health autorities have the responsiblity to develop policy to guide staff in these types of situations while also protecting the health care provider's right to refuse to administer treatments, reviewed on a case by case basis.

Anonymous

nurses duty is to advocate for their patients ;they should have a process in place to refuse when ethically they feel the patient is not competent or is being unduly influenced by others. Assited death must be humane. First, I would prefer we have excellent end of life care with palliation Worried.. we must develop strong, clearly defined guidelines on assited suicide, we need definitions of competence, intolerable suffering (is this physical,psychological or both.) Nurses are with the patients 24/7; we can help develop a program that repsects the person right to personal choice yet at the same time adhere to our code of ethics.

Anonymous

#2. Under no circumstances should a nurse or doctor have an obligation to participate in assisted death. The professional's moral conscience should not be imposed upon. Legislation in other instances speaks to this and I would hope will be included in NB legislation. #3.It is important for nurses to maintain a non-judgmental view to their patients beliefs and care. Discussions should be factually based and informative but not coercive, either way. Nurses have a special place in their patients lives and healthcare based upon their degree of caring, compassion, trust, and skill. The feelings/beliefs of the nurse cannot infringe upon the needs of the patient. Any nurse who cannot have a therapeutic conversation with a patient on this topic should relent this or all aspects the patient's care to someone who is able to go through this journey with the patient.

Anonymous

As with other situations that may go against a nures's personal moral conviction, nurses must have the right to decline participation in assisted death. But as nurses must provide care to all people regardless of their own views, nurses must be able to help patients find someone else who will help them. To avoid these problems there should be a dedicated team who will provide the "best practice" for patients seeking an assisted-death whether it be in a hospital, hospice or at home.

Anonymous

There must be protection to us as nurses to decline in taking part in assisted suicide. I could never assist with this. It goes against my spiritual beliefs and also everything I practise as a medical professional. Please make sure we are never forced to take part in this.

Anonymous

I did Hospice nursing in the community both in Australia and 3 provinces in Canada. I am no longer in that nursing specialty and retrospect can often enlighten wisdom. Far too often in the community I was faced with a young person dying of a intractable painful disease . Often I had people plead with me to end their life day after day and I honestly believe it was my nursing professional standard, training that helped me stand my ground and not enter into an assisted suicide agreement. In light of that, I would still encourage that community health nurses be given a lot more support, time for discussion, buddy system sharing of patients and counselling on how to be compassionate and supportive without being involved in an action that could place a patient and them at risk . When you are the only professional person and face a family sees daily it can become a real pressure .... Thanks for the opportunity to voice this. Anonymous Feb 16th

Anonymous

This is an abstract from one study that looked at reported rates of nurses participating physician-assisted death. The results suggests that nurses are very involved in this procedure. However the study is about 10 years old and things may have changed. It is titled "Involvement of nurses in physician-assisted dying" by Johan J.R. Bilsen MSc RN, Robert H. Vander Stichele MD, Freddy Mortier PhD andLuc Deliens PhD and was published in JAN. Article first published online: 23 AUG 2004 Aim.  This paper reports the findings of a study that investigated how often nurses are consulted by physicians in the decision-making process preceding end-of-life decisions and how often nurses participate in administering lethal drugs in end-of-life decisions. Method.  Data were collected within a nationwide cross-sectional retrospective death certificate study in Flanders, the Dutch-speaking part of Belgium. We selected 3999 deaths, a 20% random sample of all those occurring during the first 4 months of 1998. Anonymous questionnaires were mailed to the physicians who signed the death certificates. Several questions concerned the involvement of nurses in end-of-life decisions. Results.  We received 1925 valid questionnaires. For all reported end-of-life decisions (39·3% of all deaths in Flanders), physicians provided information about the involvement of nurses. Physicians consulted at least one nurse in 52% of end-of-life decisions cases occurring in institutions, compared with 21·4% of such cases at home. Nurses administered lethal drugs in 58·8% of euthanasia cases occurring in institutions and in 17·2% at home. For cases in which life was ended without the patient's explicit request because, predominantly, they were too ill to do so, these percentages were respectively 82·7% and 25·2%. In institutions, nurses mostly administered drugs without the attendance of a physician who had prescribed the drugs. Conclusions.  Nurses in Belgium are largely involved in administering lethal drugs in end-of-life decisions, while their participation in the decision-making process is rather limited. To guarantee prudent practice in end-of-life decisions, we need clear guidelines, professionally supported and legally controlled, for the assignment of duties between physicians and nurses regarding the administration of lethal drugs to reflect current working practice. In addition, we need appropriate binding standards governing mutual communication about all end-of-life decisions.

Anonymous

This topic is interesting particularly because we seem to have more elderly people in our hospitals waiting for nursing homes. As a nurse, we already participate in areas which are grey and will continue to face challenges with no easy fix. Personally I would not want to work in a prison for example, where there is the death penalty and as a staff employed in such an institution, I would not want the responsibility of carrying out the death of another human being. Assisted suicide is rather a negative term. Suicide to me can be selfish and not always decided with a clear and healthy mind. I think as a nurse, would I be "in the right" to have my morals/belifs interfere with the decisions my patients want to rightfully make? the answer is no. It is no different in some respects than abortion. I do not understand each individuals situation, their past , their present,future, I am not "in their shoes". Would I want another human being to interfere negatively in my personal choices even rights? My personal views as a nurse really should be set aside, that is not to say that from personal family history of suicide that a choice of suicide is often not isolated and famiy /friends etc live on after their loved one has died by suicide. This should be opened up for more communication as well as education from all levels in society not just the medical field.

Anonymous

I believe in certain cases it is very humane to participate in assisted death but there would have to be strict criteria such as intolerable suffering and a definite palliative diagnosis. I also agree that this would have to be a multidisciplinary approach where all the team members involved in the patient's care agree that this would be in the best interest of the patient if he or she wishes.

Anonymous

1. Competency would need to be assessed by a minimum of 2 physicians, and they must be able to take into account any pain medications the patient may be on, neither writing off the patients ability to make competent decisions while "under the influence", nor simply allowing for the fact that if the patient is taking so many narcotics they must be suffering greatly. 2. No nurse should be forced to perform any act or duty which goes against his/her moral conscience. All nurses, however, have the duty to provide all patients with the best of care, if they feel unable to do so, it is their duty to find someone who can and will assist the patient as needed. 3. If a patient asks a question, it is the nurse's responsibility to provide patient education to the best of his/her ability in a forthright, factual manner, showing no bias either way. The nurse must refrain from giving her personal opinion on the issue, even if asked by the patient.

Anonyme

Bonjour, Il est certain que des critères rigides doivent être mis en place. Le patient doit être en mesure de faire un choix éclairé; toutes les options doivent lui avoir été expliquées et documentées par le médecin. Je crois qu'étant une décision fatale, un deuxième médecin devrait valider la décision du patient en question. Je ne crois pas qu'une telle décision peut être mise dans un testament de vie ou directives en cas d'inaptitude car trop de possibilités et la décision ne peut certainement pas être éclairée étant prise plusieurs années à l'avance. Je crois qu'il revient au médecin d'administrer le médicament car plusieurs circonstances peuvent se produire qui ne permettent pas à l'infirmière d'agir. L'infirmière aura cependant un rôle à jouer par rapport à l'enseignement et l'information que le patient a besoin pour prendre sa décision. Les infirmières devront avoir les outils nécessaires. La discussion peut se faire un peu n'importe où selon la condition du patient. Ça peut être au bureau du médecin, à l'urgence, étant hospitalisé ou en foyers de soins. Cette décision devrait toujours être validée par un second médecin et ne pas être prise sous pression; il devrait y avoir au moins une semaine entre la discussion et la décision finale. Ce sont là mes commentaires!!

Anonyme

Il faut faire très attention pour que ce soit la décision de la personne et d'aucune personne de son entourage,lui ou elle seule doit décider ,nous somme responsable de s'assurer aussi que cette personne n'est pas suicidaire ,mais simplement prète a finir de souffrire innutilement et non parce qu'elle ne trouve plus de raisons de vivre.Soigner c'est aussi aider les gens a bien mourir ,en respectant leur choix.j'était là quand ma soeur et ma mère sont morte et j'aurait tellement aimé pouvoir les aidés a aténuer leur souffrances quand elles m'ont demandés de les aidés a mourir plus vite.

Anonymous

While I agree there are a lot of elderly folks who are in hospital waiting for nursing homes, that does not mean they would prefer/request death rather than living in a nursing home. Many still want to be resuscitated and their next of kin and POA respect this position. Contrary to perceptions of many, the quality of life is often enhanced in a Nursing home for certain individuals who would otherwise be housebound or hospital bed bound. I would be concerned if AGE(elderly) becomes a determining variable. An argument could also be made for individuals challenged by mental illness( young adults), parents of children with disabilities etc. Competency of the patient would need to be objectively measured or if incompetent or underage, can the alternate decision maker "choose" and would their "competency" also need to be ascertained-care giver burnout would need to be somehow assessed. Intolerable suffering seems subjective and I also wonder if we mean physical or psychological... I agree with comments made that the professionals need to maintain objectivity and remove themselves from relationships which are not therapeutic....what I can endure and accept might be very different than what another could endure or accept...how much pain and suffering and debilitation would I endure to see my children grow and "walk down the aisle" vs what would I expect them to witness .... An RN can be drawn into a conversation at any time ...should be initiated by the patient or alternate decision maker and referred to the "evaluative" team with the patients consent.

Anonymous

Would nurse & Doctors have the option to refuse to participate?And what are the repercussions if one refuses?Can a patient's POA make trhe decision on their behalf?

Anonyme

Les critères doivent bien définis et la personne doit être lucide afin de bien comprendre les explications à ce sujet. J'ajouterais aussi "l'aide à mourir AVEC DIGNITÉ"...La famille devrait aussi être impliqué, plutôt informé, mais la décision finale demeure celle du patient! L'infirmière est une personne humaine avec ses propres croyances morales. Si cette acte va à l'encontre de ses convictions elle ne peut être forcer à le faire! Toutefois elle doit s'organiser pour procurer les soins nécessaires au patient. L'infirmière étant la professionnelle de l'équipe multidisciplinaire la plus présente auprès du client, il ne va sans dire qu'elle doit être bien outillé à tous les niveaux que ce soit informatif ou sa capacité de donner un support morale au client et ses proches! On ne peut généralisé...chaque cas est différent mais un testament de vie bien précis peut parfois faciliter le processus en mon opinion!

Anonyme

Premièrement, je crois que cette décision est pour le mieux. Je crois que chaque personne a le droit de mourir dans le respect et la dignité, une decision qui était souvent impossible en fin de vie. Pour ce qui est de cette décision, le patient, ainsi que l'équipe multidisciplinaire, incluant un médecin généraliste et un psychologue devrait être d'accord. L'était mental de la personne ainsi que physique doivent être pris en ligne de compte. Aucune infirmière devrait être obligé de participer à l'aide à mourir, mais elle a le devoir d'informer le patient et de lui donner le soutien nécessaire (soit en trouvant quelqu'un qui peut le prendre en charge si nécessaire) Une discussion sur l'aide à mourir peut avoir lieu à n'importe quel moment ou endroit dans lequel le patient est confortable, mais le médecin pourrait probablement débuter la discussion.

Anonyme

C'est un debat qui merite une grande reflexion.La competence mentale du patient pour consentir a mettre fin a sa vie devrait etre evaluee et etablie par son MD traitant et un psychiatre. Tous et chacun reagissent differemment a une douleur,mais ,je crois qu'un patient adulte devrait pouvoir consentir a mettre fin a sa vie dans le respect et la dignite. Dans le cas d'enfant ou de personne vivant avec un handicap qui ne peuvent prendre cette decision du^ a leur jeune age ou leur incapacite intellectuelle ou cognitive,la personne responsable....cet aspect sera tres difficile a etre defini par les lois. Une infirmiere ne peut pas etre obligee de participer a l'aide a mourir si cet acte va a l'encontre de ses valeurs et ses croyances morales. Par contre,elle a la responsabilite de trouver de l'aide et de l'information pour assister le patient dans cette demarche. Les infirmieres sont les personnes les plus pres des gens qui vivent des moments difficiles et la discussion peut avoir lieu a n'importe quel moment. Je suis d'accord qu'un testament de vie bien precis peut faciliter le processus et surtout informer nos proches de notre reflexion sur la fin de la vie en tout respect et dignite.

Anonymous

I applaud this supreme court decision because I believe it gives patients autonomy in their health care decisions. I do hope that NANB and CNA develop specific guidelines on the role of the nurse in assisted death and how it applies to our code of ethics and practice. I believe that nurses and all health care workers should have refusal rights but should also not work in areas where this is most common,if it goes against their personal beliefs. Patients deserve care based on their autonomy and beliefs, not the nurses or drs. I think it is the role of the physician to have the initial conversation about this topic and I worry if they actually will. I have noticed many physicians are leery/ avoid discussing code status and DNR orders with patients and likely this would be an even more sensitive topic. As a nurse, I can discuss it with the patient but if the physician dismisses it or disagrees, the patients wishes are not respected.I think in general , all members of the health care team need to discuss all end of life options and earlier rather than later.

Anonymous

As a nurse, I want to alleviate and prevent the unnecessary suffering of any human being. I respect the right of a competent individual to make his or her own choice regarding physician assisted suicide. The guidelines for determining competency need to be clear and strict.I fear that age, mental illness, and disability will become determining factors in the decisions made by POAs or caregivers. One must be certain that this was the decision of the person WHILE this person was competent. I think that doctors and nurses must be allowed to refuse to participate in this practice.Regardless of the language used to soften this practice by calling it "physician assisted " suicide, it is planned and deliberate participation in the death of another human being. My religious beliefs do not permit me to be a part of this process.

Anonymous

From my understanding of physician assisted suicide we do not have to worry about this being done to someone. Those who wish to participate in their own death,fearing terrible suffering or pain will search out help for themselves. Discussion regarding DNR status is a completely different conversation.

Anonymous

As a nurse I feel this is an issue that requires one to have some serious self reflection on how they feel about assisted death. As health care providers our goal is to alleviate unnecessary suffering and honor the wishes of our patients. However I also feel that there is enough uncertainty amongst nurses that we require very clear guidance about our professional rights, roles and responsbilities when caring for people choosing assisted death. A nurse should never be placed in a position where they feel forced to participate. I think it is imperative that Physicians at least initiate conversations with patients as early as possible in their disease/disability process. Nurses can support clients in their decision making, but the issue needs to be raised first by the physician responsible for their care and for deeming whether their condition is irremediable. It should be a standard of care.The impact of the physician and nurses thoughts on assisted suicide could greatly impact the patient decision.

Anonymous

I was so relieved to hear the Supreme Courts decision in this matter. I just hope, for the sake of those patients who are already suffering, that the legislators will agree and pass the bill here in this country soon before more unwanted and unnecessary suffering occurs. I too have been a community nurse for 20+ years looking into the faces of patients who can no longer endure unretractible pain and suffering. They should have the right to die with dignity. I too have religious and moral beliefs but choosing when you die is not playing God or is not an unforgivable sin. That being said, let's keep our religious beliefs aside and put ourselves in the shoes of those who are currently suffering, and worse ... know what is likely to come in the end. I remember the day when we had similar discussions around other such ethical debates. Let's just be sure we do this one right. Provide nurses the education, guidelines and standards for which we can participate if we wish to. More importantly, we as nurses need a voice when it comes to dying with dignity. We should be able to discuss freely with legislators, physicians and more importantly clients when they ask questions around what the patients' options might be for end of life care, including being able to die with dignity. Nurses are the ones often closest emotionally, spiritually and physically to the patients so being the first person they talk to about the topic should be ok too. Drs often hesitate discussing DNR with clients; so having this discussion ... well the hesitation will be there too and most likely worse. Needless to say ... I have been waiting for this ruling for a long time (30+ years).

Anonymous

A Nurse or Doctor should NEVER be forced into participating with Physician-assisted suicide!

Anonymous

I'm very glad to see this news. I have been an advocate of this being a legal option for persons with debilitating, uncurable conditions which cause their last days to be painful and their exit from life not at their choosing. Throughout our marriage, my husband and I had always discussed having that choice, and ensuring we could do so, should we be faced with such a situation. I myself have worked with palliative patients in both acute surgical settings as well as community ones (as an EMP nurse) and also witnessed the painful and long passing of my mother in law as well. To see someone you care for, patient or family, beg for help and in such suffering I think has to make you feel physician-assisted suicide must be an option and long past due in this country. I do agree there needs to be a clear, detailed process for such things although one that can be dealt with in an amount of time reasonable considering the patient's current suffering and disease process. I don't feel the moral feelings of the caregiver should have any impact on the process - but then perhaps it is because I feel strongly about this being available due to personal experiences. I do feel HCPs should be able to opt out of the process, if the HCP can replaced reasonably quickly and it would not cause undue delay in the process, if the patient is already suffering. In that case, to me, that would constitute some sort of professional or moral abandonment when they require us the most, and our first professional responsibility is to care for that patient in need to the best of our abilities. I'd hate to see it become an issue (and it should legally NOT be allowed to become) where it becomes a available but difficult service to access, like abortion, where there are facilities not willing to provide the services (due to the feelings of administrators or physicians, and protests at the hospitals), nurses and physician refusing (and thus further reducing access), with the patients suffering in the meantime while the politics play out, and those with lower financial and support means suffer most. Someone earlier mentioned having a 'team' that assists in the process - great idea - perhaps several palliative specialists as well as specialist nurses would be excellent to provide support to the various units and HCPs that would be involved in the situation.

Anonyme

J'aimerais (en tant qu'infirmière) avoir la possibilité de participer à des rencontres et discussions en personne avec des médecins en soins palliatifs et des juristes pour comprendre toute la portée de cette loi. Je travaille dans un foyer de soins et je suis inquiète....on entend toutes sortes de commentaires.Je craind un glissement de la qualité des soins en fin de vie. C,est bien un forum virtuel mais j'aimerais que mon association organise des ateliers dans les milieux de travail.

Anonymous

I will think like the nurse that I have been for over 25 years, assisting her patient and thinking of them first. I will put my religious beliefs aside and I will look objectively at the suffering happening in our hospitals, nursing home and in each of the patient that were able to stay home for their care. However, I still cannot believe that in 2015, we still are not able to relieve suffering whether physical or psychological, by any other mean than by planning an assisted suicide. I also cannot believe that people think that the patients who do not choose that option are not dying with dignity. This word needs to be defined. Without being one myself, there are wonderful palliative care nurses who have assisted patients and relieved the suffering not only of the dying patient but of their family and had that patient die with the highest dignity. One must wonder if it is not the society that cannot bear suffering, not the patient and this alternative would ease the society not the patient. Dignity for who? We must look at the care we are giving right now and how come we are not answering the needs of our patients? When a patient is unable to meet his own needs and nobody is there to help him meet them, I am not certain that it's the disease, the disability or the pain that becomes unbearable, it's the deprivation, it's the despair, it's the atrocious feeling one has of being a burden. Is this what we want to relieve? the burden? How can one patient with such unbearable disabilities and limitations fight to live while one can't? Are we caring for the right thing? Who will define which suicide is acceptable and which one requires admission in a locked unit? For those of us who held the hand of the dying and provided the upmost care to assure the needs of that patient, I do not believe they would have chosen to die any other way, as they were surrounded by caring, a caring that brought dignity to their death.

Anonymous

ALTHOUGH I AGREE WITH THIS RULING AND KNOW IT WILL HELP BRING AND END TO THE NEEDLESS PAIN AND SUFFERING THAT GOES ON AT THE END OF LIFE, I CANT HELP BUT WONDER HOW INSURANCE COMPANIES AND BENEFICIARIES OF LIFE INSURANCE MAY HASTEN THE DECISION TO END A LIFE BASED ON PERSONAL FINANCIAL GAINS OR LOSSES. ITS NOT NICE TO SAY BUT OFTEN TIMES MONEY MAKES FAR MORE DECISIONS THAN WE LIKE TO ADMIT

Anonyme

Je considère qu'il était plus que temps que des changements soient apportés à cette loi. Chaque personne a le droit de mourir dans la dignité. Le défi consiste à s'assurer que la personne soit capable de donner un consentement éclairé ( connait toutes les options, les impacts de chacune, peut en discuter, etc...). Les outils existent, les gens dans ce domaine peuvent nous aider à cet effet, afin de préciser les lignes directrices assurant un consentement éclairé. L'infirmière doit clarifier ses propres valeurs quant à l'aide à mourir, à mourir dans la dignité, à son rôle face à ceci. Si elle ne peut faire la part des choses entre valeurs personnelles, valeurs professionnelles et valeurs du client, pour le meilleur intérêt du client, c'est sa responsabilité de le signifier et de s'assurer qu'une autre infirmière prenne alors la relève. Différents formats doivent être envisagés pour engager la réflexion et la discussion: webinaires sur le sujet avec des chercheurs dans ce domaine rapportant les façons de faire, des lectures supplémentaires, des témoignages (de clients, de familles, d'intervenants: mds, et infs) déposés sur le site de l'AIINB constitueraient une approche non-menaçante de s'informer et de permettre de se faire une opinion, des forums régionaux pourraient permettre aux infirmières de discuter en groupe de ceci.

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