Health professionals’ understanding and attitude towards the End of Life Choice Act 2019: a secondary analysis of Manatū Hauora – Ministry of Health workforce surveys
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As of January 2023, Aotearoa New Zealand is among the 25 jurisdictions/countries that have legalised assisted dying (AD).[[1–3]] The New Zealand End of Life Choice (EOLC) Act 2019 (the Act) came into force in November 2021 following a twelve-month implementation process. In New Zealand, AD practice encompasses euthanasia and physician-assisted dying, allowing a person with a terminal illness to request medication to end their life if they meet strict criteria.
As a recent addition to New Zealand health services, AD has implications for all health professionals. The Act stipulates that a health practitioner is entitled to conscientiously object to providing AD (Section 8[1] of the Act).[[4]] Such practitioners are not legally required to disclose their conscientious objection; however, they do have a duty of care to respond when AD is raised. This duty includes informing the patient of their right to seek a replacement practitioner and providing them with information about AD (Sections 9[2] and 10[2] of the Act).[[4]] This requirement highlights the necessity for all health professionals to be familiar with (1) the AD service and its care pathways, (2) the Act and its regulatory framework, eligibility criteria, and key safeguards, and (3) the three statutory roles established under the Act, including the Registrar (AD), the Support and Consultation for the End of Life in New Zealand Group, and the Review Committee.[[5]]
The availability of a workforce to provide AD is partly contingent on health professionals’ competency and knowledge of the Act and AD services. International studies have highlighted the emotional and psychological burdens of providing AD on health professionals and the impact of these burdens on workforce availability if left unaddressed.[[6–8]] Given that health professionals in New Zealand will increasingly encounter patients requesting AD, it is important to gain insight into their knowledge and attitudes towards the Act. This insight would help with the provision of AD services by ensuring support is available and minimising the burdens on the workforce.
Manatū Hauora – Ministry of Health (the Ministry) oversees the implementation of AD services in New Zealand and conducted two workforce surveys prior to the implementation of the Act. The purpose of these surveys was to gather baseline national workforce data in relation to the provision of AD. In this study, we analysed survey data to determine the socio-demographic factors associated with health professionals’ understanding of the Act, support for and willingness to provide AD.
Methods
Research design
This study is a secondary analysis of two surveys conducted by the Ministry in February 2021 and July 2021. Ethics approval was obtained from The University of Auckland Human Participants Ethics Committee (Reference Number UAHPEC24110).
Participants and setting
The Ministry used snowballing sampling and distributed the two anonymous online surveys to a range of organisations with a request to disseminate the invitation to their health professional members and other relevant networks. These organisations included district health boards, hospices, medical colleges (e.g., general practice, palliative care, and psychiatry), New Zealand Nurses Organisation, education providers (e.g., medical schools), allied organisations (e.g., Cancer Control Agency), government agencies (e.g., Department of Corrections, Te Puni Kōkiri, Disability Support Services, Health Quality & Safety Commission, and the Health and Disability Commissioner), Māori health services and associated organisations, disability organisations, and advocates for aged care (e.g., Age Concern). The first survey was open for four weeks and the second for three weeks.
Workforce surveys
The Ministry developed both surveys. Surveys One and Two contained 14 identical questions collecting respondents’ age, gender, ethnicity, health profession, work setting, and location, as well as their understanding of the Act, education/training preference, and areas of interest. The surveys also contained disparate questions. Survey One asked respondents about their support for and willingness to provide AD. Survey Two asked questions on whether respondents had completed and found the Ministry training modules and webinars useful. A combination of “Yes”/“No” answers, Likert Scales, and free-text answers were used, and each survey took approximately 10 minutes to complete. This study analysed responses to the subset of questions listed in Table 1 that were most relevant to the research objectives.
View Tables 1–7.
Data cleaning and analysis
We used Microsoft Excel 365 (Version 2202) to re-categorise and re-code some variables to allow comparisons across the two surveys, and Statistical Package for Social Sciences (SPSS) software, Version 28.0 (IBM), for data analysis. We performed Spearman’s rank correlation analyses for questions related to the “understanding of the Act” section (Table 1): overall understanding, understanding of eligibility criteria, and understanding of obligations and the right of conscientious objection. We found significant correlations (p≤0.05) between the responses to these three questions and decided to use only “overall understanding” as the overarching question in subsequent analyses. Descriptive statistics (number and percentages) were calculated to describe socio-demographic information with respect to three main outcomes: overall understanding of the Act, support for, and willingness to provide AD.
Logistic regression was used to assess associations between the socio-demographic variables (independent variables) and the three main outcomes of interest (dependent variables). We dichotomised the responses to the questions on “overall understanding of the Act” and “willingness to provide AD” (refer to Table 1 for details). Odds ratios were reported with a 95% confidence interval. Statistical significance was set at the 5% level.
Results
Survey One received 1,980 responses. Most respondents were older than 45 years (58.1%), female (62.6%), Pākehā/European (81.4%), and worked as medical practitioners (73.4%) in a hospital setting (44.2%). There were 27 (1.4%) and 12 (1.4%) Māori respondents in Survey One and Two respectively. Survey Two had 859 responses and a notably higher proportion of nurses and nurse practitioners (Survey One: 11.1%, Survey Two: 26.4%). All 20 district health boards were represented in both surveys. Table 2 shows the socio-demographic details of the respondents.
Table 3 and Table 4 show the results of “Overall understanding of the Act” in Survey One and Survey Two, respectively. In Survey One, 14.2% of health professionals reported having a very good understanding of the Act. While52.3% reported a good understanding, 31.8% reported limited understanding, and 1.7%had no understanding of the EOLC Act (Table 3). Table 4 shows a similar distribution of these responses in Survey Two. Seventy-four point one percent of Māori participants had a good or very good understanding of the Act in Survey One and 33.3% in Survey Two.
Table 5 shows the results of “Support for AD” in Survey One, while Table 6 shows the results of “Willingness to provide AD” in Survey One. We found 46.9% of health professionals supported AD, while only 9.8% would ‘‘definitely” provide AD services. Sixty-six point seven percent of Māori participants supported AD in Survey One, but only 3.7% would ‘‘definitely” be willing to provide AD services.
Table 7 shows the results of the logistic regression analyses. In Survey One, health professionals aged 55–65 years (OR=1.46, 95% CI=1.06–2.00) and over 65 years old (OR=3.17, 95% CI=1.83–5.48) were more likely to have a good or very good understanding of the Act when compared to those aged under 35 years. In addition, health professionals working in hospice (OR=9.68, 95% CI=1.68–55.70) were more likely to have a good or very good understanding of the Act compared to aged residential care. Similar logistic regression results on “Overall understanding of the Act” were found in Survey Two, which shows consistency across the two surveys.
Several factors were found to be associated with lower support for AD: female gender (OR=0.79, 95% CI=0.64–0.97), health professionals in the South Island (OR=0.78, 95% CI=0.62–0.97), and Asian (OR=0.59, 95% CI=0.42–0.84) and ‘other’ ethnicities (OR=0.58, 95% CI=0.35-0.95) when compared to Pākehā/European. Conversely, nurses (OR=1.83, 95% CI=1.24–2.69) and ‘other’ health professionals such as allied health professionals, physio/occupational therapists, and psychologists (OR=4.76, 95% CI=2.38–9.49) were more likely to support AD than medical practitioners.
Women (OR=0.52, 95% CI=0.37–0.74) were less likely to be willing to provide AD than men. In contrast, nurses (OR=4.24, 95% CI=2.47–7.29), pharmacists (OR=4.12, 95% CI=1.68–10.08), and ‘other’ health professions (OR=4.32, 95% CI=2.14–8.75) were more likely to be willing to be part of providing AD services than medical practitioners who can directly provide AD.
Discussion
This is the first New Zealand study describing socio-demographic factors associated with health professionals’ understanding of the Act, support for and willingness to provide AD services in the year before the implementation of voluntary AD. In New Zealand, several studies[[9–15]] were conducted before the AD legislation was passed to investigate public and health professional support for AD and socio-demographic factors that may influence this attitude. Support for AD in the past 20 years has been relatively stable, averaging about 68% among the New Zealand public.[[16]] The key findings of this study were: (1) older health professionals (age>55) had a better overall understanding of the Act than younger health professionals (age<35), (2) female health professionals were less likely to support AD and be willing to provide AD, (3) Asian and ‘other’ health professionals were less likely to support AD when compared with Pākehā/European professionals, (4) nurses were more likely to support and be willing to play a role in AD provision when compared with medical practitioners who can directly provide AD, and (5) pharmacists were more likely to be willing to provide AD when compared with medical practitioners.
Age, understanding of the Act, and support for AD
We found older health professionals had a better understanding of the Act. Older health professionals may have a higher AD literacy because they have been exposed to AD debates for longer, since the first AD Bill was introduced in New Zealand in 1995. Over the 26 years between introducing the first bill and legislation coming into effect, these debates addressed topics such as what should be included in AD legislation, the decision-making process, and the level and legitimacy of the authorities given to those involved in the practice.[[17]] Similarly, health professionals working in hospices were found to have a better understanding of the Act, probably because they would have been exposed to the AD debate in their workplace due to the nature of their work caring for terminally ill people.[[18]] In terms of age, a systematic review of physicians’ and nurses’ motivations to practice AD shows older practitioners are more inclined to provide AD.[[19]] Although we did not find any association between age and support for or willingness to provide AD among health professionals in our study, our results are consistent with a previous New Zealand study which found age having a negligible association with acceptance of AD among the public,[[9]] while mixed results about the correlation between age and support for AD were reported in other New Zealand studies.[[10,16,20]]
Gender, support for and willingness to provide AD
Our study found female health professionals were less likely to support or be willing to provide AD compared to their male counterparts. This finding is consistent with previous international reviews where male physicians and nurses are more likely to support AD.[[19,21]] By contrast, several studies of the New Zealand public have reported support for AD is similar in both genders.[[10–12,16]] It appears that the relationship between gender and support for AD varies between the public and health professionals in New Zealand. Given that we could not identify any literature exploring this difference, future studies are needed to examine this potentially important finding.
Ethnicity and support for AD
Compared to the predominant European ethnicity, support for AD was significantly lower among Asian and ‘other’ ethnicities. Previous studies of the New Zealand public have also found Asian and Pacific people were less supportive of AD.[[10–12]] There has been no previous New Zealand research focussed on Asian health professionals’ perspectives on AD, and international literature on this matter is scant. The limited international literature on exploring culture-specific attitudes towards AD has concluded that some non-White ethnic groups, such as Asians, tend to show more humility and accept that not all parts of one’s life can be controlled or decided by humans.[[22]] Of note, no Asian countries have yet legalised AD, which provides an additional indication of possible cultural factors in Asian attitudes towards AD.
Previous New Zealand studies on the general population have shown mixed results regarding support for AD amongst Māori, with some studies reporting very high support at or above 65%,[[10,11]] or lower support than expected compared to other ethnicities.[[12]] However, our study did not find any association between Māori health professionals and their support for AD or willingness to provide AD services. Further research into the perspective of Māori public and health professionals on AD and the Act is needed. While mana motuhake (autonomy and self-determination) is important for Māori, this must be balanced against wairua (spiritual) and wider whānau responsibilities. Previous research has raised concerns about the potential harm to Māori if AD is practiced without a full and meaningful understanding of the relationship between mātauranga Māori and AD.[[13]] Regardless, Māori health professionals have welcomed the opportunity to debate AD kaupapa (agenda), and those who participated in the survey have shown relatively high support for AD. There is a gap in knowledge regarding the link between understanding and willingness to be involved in AD from Māori health professionals’ perspective.
Professional background, support for and willingness to provide AD
Nurses in this study were more likely to support AD and be willing to provide AD when compared with medical practitioners. Existing studies suggest that there is a difference between nurses’ and physicians’ opinions about AD.[[15]] Other New Zealand studies have also shown nurses are more likely to support AD than physicians,[[12,14–16]] which is consistent with research elsewhere.[[23,24]] Nurses are often intimately involved in the care of patients seeking AD and are often the first point of contact in AD requests.[[24]] Motivations to support AD have arisen from caring for people at the end of life prior to the introduction of the Act and witnessing suffering, despite best efforts in palliative care and sedation. However, the statutory and professional guidelines provide limited information on nurses’ scope of practice regarding AD.[[14,26]]
Given the implications for registered nurses under the Act, New Zealand nurses’ regulatory authorities and professional organisations need to support government policy statements ensuring appropriate support is given to those requested AD regardless of the nurses’ stances on AD.[[14,26]] In the Act’s statutory framework, only the role of attending nurse practitioners has been recognised as a practitioner who can legally prescribe and administer AD medication. However, this must take place under the instruction of an attending medical practitioner (Section 4[b] of the Act).[[4]] However, nurse practitioners are not legally allowed to assess AD eligibility despite evidence suggesting they have the competency to do so.[[27]]
Registered nurses’ (RN) roles and responsibilities are, on the other hand, unclear. RN responsibilities may include involvement in practical activities for AD preparation and administration, such as inserting intravenous lines and drawing up medications. The pressure felt by nurses to participate in AD to uphold their duty of care, even though conscientious objection is legally allowed, coupled with a lack of clarity around their obligations and protection, has raised concerns that need to be addressed.[[28]] Results from this study show that nurses and those identified as ‘other’ health professionals were more likely to support AD. In contrast, nurses, pharmacists, and ‘other’ health professionals were more willing to be involved in providing AD when compared to medical practitioners who have a direct role in relation to the AD provision. To better understand the contribution to AD services from various health professionals, further evidence must be generated. For example, under the Act regulation, pharmacists are involved in AD services by dispensing lethal medication. Pharmacists’ willingness for a more active role in AD services could be facilitated by reforming the practice and medication protocols preparing for this role through education and resources provided for practice and continuing professional development.[[29]] Application of these potential changes may, in turn, improve the provision of AD services.
Strengths and limitations
This is the first national large-scale study specifically of health professionals’ views regarding the Act in New Zealand. It may provide the foundation for future research on attitudes and workforce data yet to be included in the New Zealand literature. A primary limitation is related to secondary data analysis where the Ministry developed and administered the two surveys; the research team was not responsible for survey content, sampling methods, or how information was collected and recorded. In addition, some issues were found concerning the design of the surveys. For example, the age groups listed in the surveys overlapped: e.g., 35–45, 45–55, and 55–65, rather than being discrete.[[30]] There were also inconsistencies in some socio-demographic variables and their response categories between the two surveys. For example, Survey One had greater granularity of professional groups and work settings than Survey Two. We used survey documentation and a consultation session with the Ministry’s staff to address these issues.
A second limitation is that we were unable to assess changes in the attitudes to AD implementation over time due to the cross-sectional nature of the surveys. Future studies can be conducted, ideally by researchers independent of the Ministry, to assess changes in health professionals’ attitudes to AD after the implementation of the Act, along with a community sample for comparison. A further limitation concerns the representativeness of the results; the Ministry did not provide a complete list of organisations to which the surveys were distributed. Thus, survey response rates could not be determined. Finally, New Zealand ethnic groups were unequally distributed in both surveys, notably including Māori (both surveys: 1.4%) and Pacific people (0.5% and 0.8% in Survey One and Two, respectively). This contrasts with the 2021 Medical Council of New Zealand workforce (Māori 4.3% and Pacific peoples 2.1%),[[31]] 2018 New Zealand Census (Māori 16.5% and Pacific peoples 8.1%),[[32]] and the 2018–19 Nursing Council of New Zealand workforce (Māori 8%).[[33]]
Conclusion
This secondary analysis of Manatū Hauora – Ministry of Health EOLC Act workforce surveys shows that socio-demographic factors such as age, gender, ethnicity, and professional background moderate health professionals’ support for and willingness to provide AD. Furthermore, an overview of the availability of an AD workforce and delivery of AD services is provided. Since AD has implications for health professionals, there is a need for all health professionals to be familiar with the Act and the AD services. Findings from this study have highlighted that certain health professionals (e.g., younger health professionals) could benefit from continuing education and professional development on these matters. Future research is needed to better understand the lower support for and/or willingness to provide AD among female and Asian health professionals. Future studies could further explore the roles of nurses and pharmacists in AD services, and future review of the Act could consider enhancing the roles of nurses and pharmacists in caring for people requesting AD, given that these professional groups are more likely to support and/or be willing to assist in providing AD services. Future research on health professionals’ experiences of being involved in AD would be beneficial to improve our knowledge as the Act is implemented.
Summary
Abstract
Aim
To determine socio-demographic factors associated with health professionals’ understanding of the End of Life Choice Act (the Act), support for assisted dying (AD), and willingness to provide AD in New Zealand.
Method
Secondary analysis of two Manatū Hauora – Ministry of Health workforce surveys conducted in February and July 2021.
Results
Our analysis showed (1) older health professionals (age>55) had a better overall understanding of the Act than their young colleagues (age<35), (2) female health professionals were less likely to support and be willing to provide AD, (3) Asian health professionals were less likely to support AD compared to their Pākehā/European counterparts, (4) nurses were more likely to support AD and be willing to provide AD when compared to medical practitioners, and (5) pharmacists were more willing to provide AD when compared to medical practitioners.
Conclusion
Several socio-demographic factors, including age, gender, ethnicity, and professional background, are significantly associated with health professionals’ support and willingness to provide AD, with likely consequences for the AD workforce availability and service delivery in New Zealand. Future review of the Act could consider enhancing the roles of those professional groups with higher support and willingness to assist in providing AD services in caring for people requesting AD.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Health professionals’ understanding and attitude towards the End of Life Choice Act 2019: a secondary analysis of Manatū Hauora – Ministry of Health workforce surveys
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As of January 2023, Aotearoa New Zealand is among the 25 jurisdictions/countries that have legalised assisted dying (AD).[[1–3]] The New Zealand End of Life Choice (EOLC) Act 2019 (the Act) came into force in November 2021 following a twelve-month implementation process. In New Zealand, AD practice encompasses euthanasia and physician-assisted dying, allowing a person with a terminal illness to request medication to end their life if they meet strict criteria.
As a recent addition to New Zealand health services, AD has implications for all health professionals. The Act stipulates that a health practitioner is entitled to conscientiously object to providing AD (Section 8[1] of the Act).[[4]] Such practitioners are not legally required to disclose their conscientious objection; however, they do have a duty of care to respond when AD is raised. This duty includes informing the patient of their right to seek a replacement practitioner and providing them with information about AD (Sections 9[2] and 10[2] of the Act).[[4]] This requirement highlights the necessity for all health professionals to be familiar with (1) the AD service and its care pathways, (2) the Act and its regulatory framework, eligibility criteria, and key safeguards, and (3) the three statutory roles established under the Act, including the Registrar (AD), the Support and Consultation for the End of Life in New Zealand Group, and the Review Committee.[[5]]
The availability of a workforce to provide AD is partly contingent on health professionals’ competency and knowledge of the Act and AD services. International studies have highlighted the emotional and psychological burdens of providing AD on health professionals and the impact of these burdens on workforce availability if left unaddressed.[[6–8]] Given that health professionals in New Zealand will increasingly encounter patients requesting AD, it is important to gain insight into their knowledge and attitudes towards the Act. This insight would help with the provision of AD services by ensuring support is available and minimising the burdens on the workforce.
Manatū Hauora – Ministry of Health (the Ministry) oversees the implementation of AD services in New Zealand and conducted two workforce surveys prior to the implementation of the Act. The purpose of these surveys was to gather baseline national workforce data in relation to the provision of AD. In this study, we analysed survey data to determine the socio-demographic factors associated with health professionals’ understanding of the Act, support for and willingness to provide AD.
Methods
Research design
This study is a secondary analysis of two surveys conducted by the Ministry in February 2021 and July 2021. Ethics approval was obtained from The University of Auckland Human Participants Ethics Committee (Reference Number UAHPEC24110).
Participants and setting
The Ministry used snowballing sampling and distributed the two anonymous online surveys to a range of organisations with a request to disseminate the invitation to their health professional members and other relevant networks. These organisations included district health boards, hospices, medical colleges (e.g., general practice, palliative care, and psychiatry), New Zealand Nurses Organisation, education providers (e.g., medical schools), allied organisations (e.g., Cancer Control Agency), government agencies (e.g., Department of Corrections, Te Puni Kōkiri, Disability Support Services, Health Quality & Safety Commission, and the Health and Disability Commissioner), Māori health services and associated organisations, disability organisations, and advocates for aged care (e.g., Age Concern). The first survey was open for four weeks and the second for three weeks.
Workforce surveys
The Ministry developed both surveys. Surveys One and Two contained 14 identical questions collecting respondents’ age, gender, ethnicity, health profession, work setting, and location, as well as their understanding of the Act, education/training preference, and areas of interest. The surveys also contained disparate questions. Survey One asked respondents about their support for and willingness to provide AD. Survey Two asked questions on whether respondents had completed and found the Ministry training modules and webinars useful. A combination of “Yes”/“No” answers, Likert Scales, and free-text answers were used, and each survey took approximately 10 minutes to complete. This study analysed responses to the subset of questions listed in Table 1 that were most relevant to the research objectives.
View Tables 1–7.
Data cleaning and analysis
We used Microsoft Excel 365 (Version 2202) to re-categorise and re-code some variables to allow comparisons across the two surveys, and Statistical Package for Social Sciences (SPSS) software, Version 28.0 (IBM), for data analysis. We performed Spearman’s rank correlation analyses for questions related to the “understanding of the Act” section (Table 1): overall understanding, understanding of eligibility criteria, and understanding of obligations and the right of conscientious objection. We found significant correlations (p≤0.05) between the responses to these three questions and decided to use only “overall understanding” as the overarching question in subsequent analyses. Descriptive statistics (number and percentages) were calculated to describe socio-demographic information with respect to three main outcomes: overall understanding of the Act, support for, and willingness to provide AD.
Logistic regression was used to assess associations between the socio-demographic variables (independent variables) and the three main outcomes of interest (dependent variables). We dichotomised the responses to the questions on “overall understanding of the Act” and “willingness to provide AD” (refer to Table 1 for details). Odds ratios were reported with a 95% confidence interval. Statistical significance was set at the 5% level.
Results
Survey One received 1,980 responses. Most respondents were older than 45 years (58.1%), female (62.6%), Pākehā/European (81.4%), and worked as medical practitioners (73.4%) in a hospital setting (44.2%). There were 27 (1.4%) and 12 (1.4%) Māori respondents in Survey One and Two respectively. Survey Two had 859 responses and a notably higher proportion of nurses and nurse practitioners (Survey One: 11.1%, Survey Two: 26.4%). All 20 district health boards were represented in both surveys. Table 2 shows the socio-demographic details of the respondents.
Table 3 and Table 4 show the results of “Overall understanding of the Act” in Survey One and Survey Two, respectively. In Survey One, 14.2% of health professionals reported having a very good understanding of the Act. While52.3% reported a good understanding, 31.8% reported limited understanding, and 1.7%had no understanding of the EOLC Act (Table 3). Table 4 shows a similar distribution of these responses in Survey Two. Seventy-four point one percent of Māori participants had a good or very good understanding of the Act in Survey One and 33.3% in Survey Two.
Table 5 shows the results of “Support for AD” in Survey One, while Table 6 shows the results of “Willingness to provide AD” in Survey One. We found 46.9% of health professionals supported AD, while only 9.8% would ‘‘definitely” provide AD services. Sixty-six point seven percent of Māori participants supported AD in Survey One, but only 3.7% would ‘‘definitely” be willing to provide AD services.
Table 7 shows the results of the logistic regression analyses. In Survey One, health professionals aged 55–65 years (OR=1.46, 95% CI=1.06–2.00) and over 65 years old (OR=3.17, 95% CI=1.83–5.48) were more likely to have a good or very good understanding of the Act when compared to those aged under 35 years. In addition, health professionals working in hospice (OR=9.68, 95% CI=1.68–55.70) were more likely to have a good or very good understanding of the Act compared to aged residential care. Similar logistic regression results on “Overall understanding of the Act” were found in Survey Two, which shows consistency across the two surveys.
Several factors were found to be associated with lower support for AD: female gender (OR=0.79, 95% CI=0.64–0.97), health professionals in the South Island (OR=0.78, 95% CI=0.62–0.97), and Asian (OR=0.59, 95% CI=0.42–0.84) and ‘other’ ethnicities (OR=0.58, 95% CI=0.35-0.95) when compared to Pākehā/European. Conversely, nurses (OR=1.83, 95% CI=1.24–2.69) and ‘other’ health professionals such as allied health professionals, physio/occupational therapists, and psychologists (OR=4.76, 95% CI=2.38–9.49) were more likely to support AD than medical practitioners.
Women (OR=0.52, 95% CI=0.37–0.74) were less likely to be willing to provide AD than men. In contrast, nurses (OR=4.24, 95% CI=2.47–7.29), pharmacists (OR=4.12, 95% CI=1.68–10.08), and ‘other’ health professions (OR=4.32, 95% CI=2.14–8.75) were more likely to be willing to be part of providing AD services than medical practitioners who can directly provide AD.
Discussion
This is the first New Zealand study describing socio-demographic factors associated with health professionals’ understanding of the Act, support for and willingness to provide AD services in the year before the implementation of voluntary AD. In New Zealand, several studies[[9–15]] were conducted before the AD legislation was passed to investigate public and health professional support for AD and socio-demographic factors that may influence this attitude. Support for AD in the past 20 years has been relatively stable, averaging about 68% among the New Zealand public.[[16]] The key findings of this study were: (1) older health professionals (age>55) had a better overall understanding of the Act than younger health professionals (age<35), (2) female health professionals were less likely to support AD and be willing to provide AD, (3) Asian and ‘other’ health professionals were less likely to support AD when compared with Pākehā/European professionals, (4) nurses were more likely to support and be willing to play a role in AD provision when compared with medical practitioners who can directly provide AD, and (5) pharmacists were more likely to be willing to provide AD when compared with medical practitioners.
Age, understanding of the Act, and support for AD
We found older health professionals had a better understanding of the Act. Older health professionals may have a higher AD literacy because they have been exposed to AD debates for longer, since the first AD Bill was introduced in New Zealand in 1995. Over the 26 years between introducing the first bill and legislation coming into effect, these debates addressed topics such as what should be included in AD legislation, the decision-making process, and the level and legitimacy of the authorities given to those involved in the practice.[[17]] Similarly, health professionals working in hospices were found to have a better understanding of the Act, probably because they would have been exposed to the AD debate in their workplace due to the nature of their work caring for terminally ill people.[[18]] In terms of age, a systematic review of physicians’ and nurses’ motivations to practice AD shows older practitioners are more inclined to provide AD.[[19]] Although we did not find any association between age and support for or willingness to provide AD among health professionals in our study, our results are consistent with a previous New Zealand study which found age having a negligible association with acceptance of AD among the public,[[9]] while mixed results about the correlation between age and support for AD were reported in other New Zealand studies.[[10,16,20]]
Gender, support for and willingness to provide AD
Our study found female health professionals were less likely to support or be willing to provide AD compared to their male counterparts. This finding is consistent with previous international reviews where male physicians and nurses are more likely to support AD.[[19,21]] By contrast, several studies of the New Zealand public have reported support for AD is similar in both genders.[[10–12,16]] It appears that the relationship between gender and support for AD varies between the public and health professionals in New Zealand. Given that we could not identify any literature exploring this difference, future studies are needed to examine this potentially important finding.
Ethnicity and support for AD
Compared to the predominant European ethnicity, support for AD was significantly lower among Asian and ‘other’ ethnicities. Previous studies of the New Zealand public have also found Asian and Pacific people were less supportive of AD.[[10–12]] There has been no previous New Zealand research focussed on Asian health professionals’ perspectives on AD, and international literature on this matter is scant. The limited international literature on exploring culture-specific attitudes towards AD has concluded that some non-White ethnic groups, such as Asians, tend to show more humility and accept that not all parts of one’s life can be controlled or decided by humans.[[22]] Of note, no Asian countries have yet legalised AD, which provides an additional indication of possible cultural factors in Asian attitudes towards AD.
Previous New Zealand studies on the general population have shown mixed results regarding support for AD amongst Māori, with some studies reporting very high support at or above 65%,[[10,11]] or lower support than expected compared to other ethnicities.[[12]] However, our study did not find any association between Māori health professionals and their support for AD or willingness to provide AD services. Further research into the perspective of Māori public and health professionals on AD and the Act is needed. While mana motuhake (autonomy and self-determination) is important for Māori, this must be balanced against wairua (spiritual) and wider whānau responsibilities. Previous research has raised concerns about the potential harm to Māori if AD is practiced without a full and meaningful understanding of the relationship between mātauranga Māori and AD.[[13]] Regardless, Māori health professionals have welcomed the opportunity to debate AD kaupapa (agenda), and those who participated in the survey have shown relatively high support for AD. There is a gap in knowledge regarding the link between understanding and willingness to be involved in AD from Māori health professionals’ perspective.
Professional background, support for and willingness to provide AD
Nurses in this study were more likely to support AD and be willing to provide AD when compared with medical practitioners. Existing studies suggest that there is a difference between nurses’ and physicians’ opinions about AD.[[15]] Other New Zealand studies have also shown nurses are more likely to support AD than physicians,[[12,14–16]] which is consistent with research elsewhere.[[23,24]] Nurses are often intimately involved in the care of patients seeking AD and are often the first point of contact in AD requests.[[24]] Motivations to support AD have arisen from caring for people at the end of life prior to the introduction of the Act and witnessing suffering, despite best efforts in palliative care and sedation. However, the statutory and professional guidelines provide limited information on nurses’ scope of practice regarding AD.[[14,26]]
Given the implications for registered nurses under the Act, New Zealand nurses’ regulatory authorities and professional organisations need to support government policy statements ensuring appropriate support is given to those requested AD regardless of the nurses’ stances on AD.[[14,26]] In the Act’s statutory framework, only the role of attending nurse practitioners has been recognised as a practitioner who can legally prescribe and administer AD medication. However, this must take place under the instruction of an attending medical practitioner (Section 4[b] of the Act).[[4]] However, nurse practitioners are not legally allowed to assess AD eligibility despite evidence suggesting they have the competency to do so.[[27]]
Registered nurses’ (RN) roles and responsibilities are, on the other hand, unclear. RN responsibilities may include involvement in practical activities for AD preparation and administration, such as inserting intravenous lines and drawing up medications. The pressure felt by nurses to participate in AD to uphold their duty of care, even though conscientious objection is legally allowed, coupled with a lack of clarity around their obligations and protection, has raised concerns that need to be addressed.[[28]] Results from this study show that nurses and those identified as ‘other’ health professionals were more likely to support AD. In contrast, nurses, pharmacists, and ‘other’ health professionals were more willing to be involved in providing AD when compared to medical practitioners who have a direct role in relation to the AD provision. To better understand the contribution to AD services from various health professionals, further evidence must be generated. For example, under the Act regulation, pharmacists are involved in AD services by dispensing lethal medication. Pharmacists’ willingness for a more active role in AD services could be facilitated by reforming the practice and medication protocols preparing for this role through education and resources provided for practice and continuing professional development.[[29]] Application of these potential changes may, in turn, improve the provision of AD services.
Strengths and limitations
This is the first national large-scale study specifically of health professionals’ views regarding the Act in New Zealand. It may provide the foundation for future research on attitudes and workforce data yet to be included in the New Zealand literature. A primary limitation is related to secondary data analysis where the Ministry developed and administered the two surveys; the research team was not responsible for survey content, sampling methods, or how information was collected and recorded. In addition, some issues were found concerning the design of the surveys. For example, the age groups listed in the surveys overlapped: e.g., 35–45, 45–55, and 55–65, rather than being discrete.[[30]] There were also inconsistencies in some socio-demographic variables and their response categories between the two surveys. For example, Survey One had greater granularity of professional groups and work settings than Survey Two. We used survey documentation and a consultation session with the Ministry’s staff to address these issues.
A second limitation is that we were unable to assess changes in the attitudes to AD implementation over time due to the cross-sectional nature of the surveys. Future studies can be conducted, ideally by researchers independent of the Ministry, to assess changes in health professionals’ attitudes to AD after the implementation of the Act, along with a community sample for comparison. A further limitation concerns the representativeness of the results; the Ministry did not provide a complete list of organisations to which the surveys were distributed. Thus, survey response rates could not be determined. Finally, New Zealand ethnic groups were unequally distributed in both surveys, notably including Māori (both surveys: 1.4%) and Pacific people (0.5% and 0.8% in Survey One and Two, respectively). This contrasts with the 2021 Medical Council of New Zealand workforce (Māori 4.3% and Pacific peoples 2.1%),[[31]] 2018 New Zealand Census (Māori 16.5% and Pacific peoples 8.1%),[[32]] and the 2018–19 Nursing Council of New Zealand workforce (Māori 8%).[[33]]
Conclusion
This secondary analysis of Manatū Hauora – Ministry of Health EOLC Act workforce surveys shows that socio-demographic factors such as age, gender, ethnicity, and professional background moderate health professionals’ support for and willingness to provide AD. Furthermore, an overview of the availability of an AD workforce and delivery of AD services is provided. Since AD has implications for health professionals, there is a need for all health professionals to be familiar with the Act and the AD services. Findings from this study have highlighted that certain health professionals (e.g., younger health professionals) could benefit from continuing education and professional development on these matters. Future research is needed to better understand the lower support for and/or willingness to provide AD among female and Asian health professionals. Future studies could further explore the roles of nurses and pharmacists in AD services, and future review of the Act could consider enhancing the roles of nurses and pharmacists in caring for people requesting AD, given that these professional groups are more likely to support and/or be willing to assist in providing AD services. Future research on health professionals’ experiences of being involved in AD would be beneficial to improve our knowledge as the Act is implemented.
Summary
Abstract
Aim
To determine socio-demographic factors associated with health professionals’ understanding of the End of Life Choice Act (the Act), support for assisted dying (AD), and willingness to provide AD in New Zealand.
Method
Secondary analysis of two Manatū Hauora – Ministry of Health workforce surveys conducted in February and July 2021.
Results
Our analysis showed (1) older health professionals (age>55) had a better overall understanding of the Act than their young colleagues (age<35), (2) female health professionals were less likely to support and be willing to provide AD, (3) Asian health professionals were less likely to support AD compared to their Pākehā/European counterparts, (4) nurses were more likely to support AD and be willing to provide AD when compared to medical practitioners, and (5) pharmacists were more willing to provide AD when compared to medical practitioners.
Conclusion
Several socio-demographic factors, including age, gender, ethnicity, and professional background, are significantly associated with health professionals’ support and willingness to provide AD, with likely consequences for the AD workforce availability and service delivery in New Zealand. Future review of the Act could consider enhancing the roles of those professional groups with higher support and willingness to assist in providing AD services in caring for people requesting AD.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Health professionals’ understanding and attitude towards the End of Life Choice Act 2019: a secondary analysis of Manatū Hauora – Ministry of Health workforce surveys
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As of January 2023, Aotearoa New Zealand is among the 25 jurisdictions/countries that have legalised assisted dying (AD).[[1–3]] The New Zealand End of Life Choice (EOLC) Act 2019 (the Act) came into force in November 2021 following a twelve-month implementation process. In New Zealand, AD practice encompasses euthanasia and physician-assisted dying, allowing a person with a terminal illness to request medication to end their life if they meet strict criteria.
As a recent addition to New Zealand health services, AD has implications for all health professionals. The Act stipulates that a health practitioner is entitled to conscientiously object to providing AD (Section 8[1] of the Act).[[4]] Such practitioners are not legally required to disclose their conscientious objection; however, they do have a duty of care to respond when AD is raised. This duty includes informing the patient of their right to seek a replacement practitioner and providing them with information about AD (Sections 9[2] and 10[2] of the Act).[[4]] This requirement highlights the necessity for all health professionals to be familiar with (1) the AD service and its care pathways, (2) the Act and its regulatory framework, eligibility criteria, and key safeguards, and (3) the three statutory roles established under the Act, including the Registrar (AD), the Support and Consultation for the End of Life in New Zealand Group, and the Review Committee.[[5]]
The availability of a workforce to provide AD is partly contingent on health professionals’ competency and knowledge of the Act and AD services. International studies have highlighted the emotional and psychological burdens of providing AD on health professionals and the impact of these burdens on workforce availability if left unaddressed.[[6–8]] Given that health professionals in New Zealand will increasingly encounter patients requesting AD, it is important to gain insight into their knowledge and attitudes towards the Act. This insight would help with the provision of AD services by ensuring support is available and minimising the burdens on the workforce.
Manatū Hauora – Ministry of Health (the Ministry) oversees the implementation of AD services in New Zealand and conducted two workforce surveys prior to the implementation of the Act. The purpose of these surveys was to gather baseline national workforce data in relation to the provision of AD. In this study, we analysed survey data to determine the socio-demographic factors associated with health professionals’ understanding of the Act, support for and willingness to provide AD.
Methods
Research design
This study is a secondary analysis of two surveys conducted by the Ministry in February 2021 and July 2021. Ethics approval was obtained from The University of Auckland Human Participants Ethics Committee (Reference Number UAHPEC24110).
Participants and setting
The Ministry used snowballing sampling and distributed the two anonymous online surveys to a range of organisations with a request to disseminate the invitation to their health professional members and other relevant networks. These organisations included district health boards, hospices, medical colleges (e.g., general practice, palliative care, and psychiatry), New Zealand Nurses Organisation, education providers (e.g., medical schools), allied organisations (e.g., Cancer Control Agency), government agencies (e.g., Department of Corrections, Te Puni Kōkiri, Disability Support Services, Health Quality & Safety Commission, and the Health and Disability Commissioner), Māori health services and associated organisations, disability organisations, and advocates for aged care (e.g., Age Concern). The first survey was open for four weeks and the second for three weeks.
Workforce surveys
The Ministry developed both surveys. Surveys One and Two contained 14 identical questions collecting respondents’ age, gender, ethnicity, health profession, work setting, and location, as well as their understanding of the Act, education/training preference, and areas of interest. The surveys also contained disparate questions. Survey One asked respondents about their support for and willingness to provide AD. Survey Two asked questions on whether respondents had completed and found the Ministry training modules and webinars useful. A combination of “Yes”/“No” answers, Likert Scales, and free-text answers were used, and each survey took approximately 10 minutes to complete. This study analysed responses to the subset of questions listed in Table 1 that were most relevant to the research objectives.
View Tables 1–7.
Data cleaning and analysis
We used Microsoft Excel 365 (Version 2202) to re-categorise and re-code some variables to allow comparisons across the two surveys, and Statistical Package for Social Sciences (SPSS) software, Version 28.0 (IBM), for data analysis. We performed Spearman’s rank correlation analyses for questions related to the “understanding of the Act” section (Table 1): overall understanding, understanding of eligibility criteria, and understanding of obligations and the right of conscientious objection. We found significant correlations (p≤0.05) between the responses to these three questions and decided to use only “overall understanding” as the overarching question in subsequent analyses. Descriptive statistics (number and percentages) were calculated to describe socio-demographic information with respect to three main outcomes: overall understanding of the Act, support for, and willingness to provide AD.
Logistic regression was used to assess associations between the socio-demographic variables (independent variables) and the three main outcomes of interest (dependent variables). We dichotomised the responses to the questions on “overall understanding of the Act” and “willingness to provide AD” (refer to Table 1 for details). Odds ratios were reported with a 95% confidence interval. Statistical significance was set at the 5% level.
Results
Survey One received 1,980 responses. Most respondents were older than 45 years (58.1%), female (62.6%), Pākehā/European (81.4%), and worked as medical practitioners (73.4%) in a hospital setting (44.2%). There were 27 (1.4%) and 12 (1.4%) Māori respondents in Survey One and Two respectively. Survey Two had 859 responses and a notably higher proportion of nurses and nurse practitioners (Survey One: 11.1%, Survey Two: 26.4%). All 20 district health boards were represented in both surveys. Table 2 shows the socio-demographic details of the respondents.
Table 3 and Table 4 show the results of “Overall understanding of the Act” in Survey One and Survey Two, respectively. In Survey One, 14.2% of health professionals reported having a very good understanding of the Act. While52.3% reported a good understanding, 31.8% reported limited understanding, and 1.7%had no understanding of the EOLC Act (Table 3). Table 4 shows a similar distribution of these responses in Survey Two. Seventy-four point one percent of Māori participants had a good or very good understanding of the Act in Survey One and 33.3% in Survey Two.
Table 5 shows the results of “Support for AD” in Survey One, while Table 6 shows the results of “Willingness to provide AD” in Survey One. We found 46.9% of health professionals supported AD, while only 9.8% would ‘‘definitely” provide AD services. Sixty-six point seven percent of Māori participants supported AD in Survey One, but only 3.7% would ‘‘definitely” be willing to provide AD services.
Table 7 shows the results of the logistic regression analyses. In Survey One, health professionals aged 55–65 years (OR=1.46, 95% CI=1.06–2.00) and over 65 years old (OR=3.17, 95% CI=1.83–5.48) were more likely to have a good or very good understanding of the Act when compared to those aged under 35 years. In addition, health professionals working in hospice (OR=9.68, 95% CI=1.68–55.70) were more likely to have a good or very good understanding of the Act compared to aged residential care. Similar logistic regression results on “Overall understanding of the Act” were found in Survey Two, which shows consistency across the two surveys.
Several factors were found to be associated with lower support for AD: female gender (OR=0.79, 95% CI=0.64–0.97), health professionals in the South Island (OR=0.78, 95% CI=0.62–0.97), and Asian (OR=0.59, 95% CI=0.42–0.84) and ‘other’ ethnicities (OR=0.58, 95% CI=0.35-0.95) when compared to Pākehā/European. Conversely, nurses (OR=1.83, 95% CI=1.24–2.69) and ‘other’ health professionals such as allied health professionals, physio/occupational therapists, and psychologists (OR=4.76, 95% CI=2.38–9.49) were more likely to support AD than medical practitioners.
Women (OR=0.52, 95% CI=0.37–0.74) were less likely to be willing to provide AD than men. In contrast, nurses (OR=4.24, 95% CI=2.47–7.29), pharmacists (OR=4.12, 95% CI=1.68–10.08), and ‘other’ health professions (OR=4.32, 95% CI=2.14–8.75) were more likely to be willing to be part of providing AD services than medical practitioners who can directly provide AD.
Discussion
This is the first New Zealand study describing socio-demographic factors associated with health professionals’ understanding of the Act, support for and willingness to provide AD services in the year before the implementation of voluntary AD. In New Zealand, several studies[[9–15]] were conducted before the AD legislation was passed to investigate public and health professional support for AD and socio-demographic factors that may influence this attitude. Support for AD in the past 20 years has been relatively stable, averaging about 68% among the New Zealand public.[[16]] The key findings of this study were: (1) older health professionals (age>55) had a better overall understanding of the Act than younger health professionals (age<35), (2) female health professionals were less likely to support AD and be willing to provide AD, (3) Asian and ‘other’ health professionals were less likely to support AD when compared with Pākehā/European professionals, (4) nurses were more likely to support and be willing to play a role in AD provision when compared with medical practitioners who can directly provide AD, and (5) pharmacists were more likely to be willing to provide AD when compared with medical practitioners.
Age, understanding of the Act, and support for AD
We found older health professionals had a better understanding of the Act. Older health professionals may have a higher AD literacy because they have been exposed to AD debates for longer, since the first AD Bill was introduced in New Zealand in 1995. Over the 26 years between introducing the first bill and legislation coming into effect, these debates addressed topics such as what should be included in AD legislation, the decision-making process, and the level and legitimacy of the authorities given to those involved in the practice.[[17]] Similarly, health professionals working in hospices were found to have a better understanding of the Act, probably because they would have been exposed to the AD debate in their workplace due to the nature of their work caring for terminally ill people.[[18]] In terms of age, a systematic review of physicians’ and nurses’ motivations to practice AD shows older practitioners are more inclined to provide AD.[[19]] Although we did not find any association between age and support for or willingness to provide AD among health professionals in our study, our results are consistent with a previous New Zealand study which found age having a negligible association with acceptance of AD among the public,[[9]] while mixed results about the correlation between age and support for AD were reported in other New Zealand studies.[[10,16,20]]
Gender, support for and willingness to provide AD
Our study found female health professionals were less likely to support or be willing to provide AD compared to their male counterparts. This finding is consistent with previous international reviews where male physicians and nurses are more likely to support AD.[[19,21]] By contrast, several studies of the New Zealand public have reported support for AD is similar in both genders.[[10–12,16]] It appears that the relationship between gender and support for AD varies between the public and health professionals in New Zealand. Given that we could not identify any literature exploring this difference, future studies are needed to examine this potentially important finding.
Ethnicity and support for AD
Compared to the predominant European ethnicity, support for AD was significantly lower among Asian and ‘other’ ethnicities. Previous studies of the New Zealand public have also found Asian and Pacific people were less supportive of AD.[[10–12]] There has been no previous New Zealand research focussed on Asian health professionals’ perspectives on AD, and international literature on this matter is scant. The limited international literature on exploring culture-specific attitudes towards AD has concluded that some non-White ethnic groups, such as Asians, tend to show more humility and accept that not all parts of one’s life can be controlled or decided by humans.[[22]] Of note, no Asian countries have yet legalised AD, which provides an additional indication of possible cultural factors in Asian attitudes towards AD.
Previous New Zealand studies on the general population have shown mixed results regarding support for AD amongst Māori, with some studies reporting very high support at or above 65%,[[10,11]] or lower support than expected compared to other ethnicities.[[12]] However, our study did not find any association between Māori health professionals and their support for AD or willingness to provide AD services. Further research into the perspective of Māori public and health professionals on AD and the Act is needed. While mana motuhake (autonomy and self-determination) is important for Māori, this must be balanced against wairua (spiritual) and wider whānau responsibilities. Previous research has raised concerns about the potential harm to Māori if AD is practiced without a full and meaningful understanding of the relationship between mātauranga Māori and AD.[[13]] Regardless, Māori health professionals have welcomed the opportunity to debate AD kaupapa (agenda), and those who participated in the survey have shown relatively high support for AD. There is a gap in knowledge regarding the link between understanding and willingness to be involved in AD from Māori health professionals’ perspective.
Professional background, support for and willingness to provide AD
Nurses in this study were more likely to support AD and be willing to provide AD when compared with medical practitioners. Existing studies suggest that there is a difference between nurses’ and physicians’ opinions about AD.[[15]] Other New Zealand studies have also shown nurses are more likely to support AD than physicians,[[12,14–16]] which is consistent with research elsewhere.[[23,24]] Nurses are often intimately involved in the care of patients seeking AD and are often the first point of contact in AD requests.[[24]] Motivations to support AD have arisen from caring for people at the end of life prior to the introduction of the Act and witnessing suffering, despite best efforts in palliative care and sedation. However, the statutory and professional guidelines provide limited information on nurses’ scope of practice regarding AD.[[14,26]]
Given the implications for registered nurses under the Act, New Zealand nurses’ regulatory authorities and professional organisations need to support government policy statements ensuring appropriate support is given to those requested AD regardless of the nurses’ stances on AD.[[14,26]] In the Act’s statutory framework, only the role of attending nurse practitioners has been recognised as a practitioner who can legally prescribe and administer AD medication. However, this must take place under the instruction of an attending medical practitioner (Section 4[b] of the Act).[[4]] However, nurse practitioners are not legally allowed to assess AD eligibility despite evidence suggesting they have the competency to do so.[[27]]
Registered nurses’ (RN) roles and responsibilities are, on the other hand, unclear. RN responsibilities may include involvement in practical activities for AD preparation and administration, such as inserting intravenous lines and drawing up medications. The pressure felt by nurses to participate in AD to uphold their duty of care, even though conscientious objection is legally allowed, coupled with a lack of clarity around their obligations and protection, has raised concerns that need to be addressed.[[28]] Results from this study show that nurses and those identified as ‘other’ health professionals were more likely to support AD. In contrast, nurses, pharmacists, and ‘other’ health professionals were more willing to be involved in providing AD when compared to medical practitioners who have a direct role in relation to the AD provision. To better understand the contribution to AD services from various health professionals, further evidence must be generated. For example, under the Act regulation, pharmacists are involved in AD services by dispensing lethal medication. Pharmacists’ willingness for a more active role in AD services could be facilitated by reforming the practice and medication protocols preparing for this role through education and resources provided for practice and continuing professional development.[[29]] Application of these potential changes may, in turn, improve the provision of AD services.
Strengths and limitations
This is the first national large-scale study specifically of health professionals’ views regarding the Act in New Zealand. It may provide the foundation for future research on attitudes and workforce data yet to be included in the New Zealand literature. A primary limitation is related to secondary data analysis where the Ministry developed and administered the two surveys; the research team was not responsible for survey content, sampling methods, or how information was collected and recorded. In addition, some issues were found concerning the design of the surveys. For example, the age groups listed in the surveys overlapped: e.g., 35–45, 45–55, and 55–65, rather than being discrete.[[30]] There were also inconsistencies in some socio-demographic variables and their response categories between the two surveys. For example, Survey One had greater granularity of professional groups and work settings than Survey Two. We used survey documentation and a consultation session with the Ministry’s staff to address these issues.
A second limitation is that we were unable to assess changes in the attitudes to AD implementation over time due to the cross-sectional nature of the surveys. Future studies can be conducted, ideally by researchers independent of the Ministry, to assess changes in health professionals’ attitudes to AD after the implementation of the Act, along with a community sample for comparison. A further limitation concerns the representativeness of the results; the Ministry did not provide a complete list of organisations to which the surveys were distributed. Thus, survey response rates could not be determined. Finally, New Zealand ethnic groups were unequally distributed in both surveys, notably including Māori (both surveys: 1.4%) and Pacific people (0.5% and 0.8% in Survey One and Two, respectively). This contrasts with the 2021 Medical Council of New Zealand workforce (Māori 4.3% and Pacific peoples 2.1%),[[31]] 2018 New Zealand Census (Māori 16.5% and Pacific peoples 8.1%),[[32]] and the 2018–19 Nursing Council of New Zealand workforce (Māori 8%).[[33]]
Conclusion
This secondary analysis of Manatū Hauora – Ministry of Health EOLC Act workforce surveys shows that socio-demographic factors such as age, gender, ethnicity, and professional background moderate health professionals’ support for and willingness to provide AD. Furthermore, an overview of the availability of an AD workforce and delivery of AD services is provided. Since AD has implications for health professionals, there is a need for all health professionals to be familiar with the Act and the AD services. Findings from this study have highlighted that certain health professionals (e.g., younger health professionals) could benefit from continuing education and professional development on these matters. Future research is needed to better understand the lower support for and/or willingness to provide AD among female and Asian health professionals. Future studies could further explore the roles of nurses and pharmacists in AD services, and future review of the Act could consider enhancing the roles of nurses and pharmacists in caring for people requesting AD, given that these professional groups are more likely to support and/or be willing to assist in providing AD services. Future research on health professionals’ experiences of being involved in AD would be beneficial to improve our knowledge as the Act is implemented.
Summary
Abstract
Aim
To determine socio-demographic factors associated with health professionals’ understanding of the End of Life Choice Act (the Act), support for assisted dying (AD), and willingness to provide AD in New Zealand.
Method
Secondary analysis of two Manatū Hauora – Ministry of Health workforce surveys conducted in February and July 2021.
Results
Our analysis showed (1) older health professionals (age>55) had a better overall understanding of the Act than their young colleagues (age<35), (2) female health professionals were less likely to support and be willing to provide AD, (3) Asian health professionals were less likely to support AD compared to their Pākehā/European counterparts, (4) nurses were more likely to support AD and be willing to provide AD when compared to medical practitioners, and (5) pharmacists were more willing to provide AD when compared to medical practitioners.
Conclusion
Several socio-demographic factors, including age, gender, ethnicity, and professional background, are significantly associated with health professionals’ support and willingness to provide AD, with likely consequences for the AD workforce availability and service delivery in New Zealand. Future review of the Act could consider enhancing the roles of those professional groups with higher support and willingness to assist in providing AD services in caring for people requesting AD.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Health professionals’ understanding and attitude towards the End of Life Choice Act 2019: a secondary analysis of Manatū Hauora – Ministry of Health workforce surveys
As of January 2023, Aotearoa New Zealand is among the 25 jurisdictions/countries that have legalised assisted dying (AD).
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