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Background: Medical assistance in dying (MAiD) was legalized in Canada in 2016, but coordination of MAiD and palliative and end-of-life care (PEOLC) services remains underdeveloped. We sought to understand the perspectives of health leaders across Canada on the relationship between MAiD and PEOLC services and to identify opportunities for improved coordination., Methods: In this quantitative study, we purposively sampled health leaders across Canada with expertise in MAiD, PEOLC, or both. We conducted semi-structured interviews between April 2021 and January 2022. Interview transcripts were coded independently by 2 researchers and reconciled to identify key themes using content analysis. We applied the PATH framework for Integrated Health Services to guide data collection and analysis., Results: We conducted 36 interviews. Participants expressed diverse views about the optimal relationship between MAiD and PEOLC, and the desirability of integration, separation, or coordination of these services. We identified 11 themes to improve the relationship between the services across 4 PATH levels: client-centred services (e.g., educate public); health operations (e.g., cultivate compassionate and proactive leadership); health systems (e.g., conduct broad and inclusive consultation and planning); and intersectoral initiatives (e.g., provide standard practice guidelines across health care systems)., Interpretation: Health leaders recognized that cooperation between MAiD and PEOLC services is required for appropriate referrals, care coordination, and patient care. They identified the need for public and provider education, standardized practice guidelines, relationship-building, and leadership. Our findings have implications for MAiD and PEOLC policy development and clinical practice in Canada and other jurisdictions., Competing Interests: Competing interests: Gilla Shapiro reports receiving a Canadian Institutes of Health Research (CIHR) 2019 Fellowship Award (MFE 171271), in support of the present manuscript. Dr. Shapiro reports receiving consulting fees from the World Health Organization, honoraria from Toronto Public Health, and a CIHR funding grant (no. 185783), all outside the submitted work. Madeline Li reports receiving a CIHR project grant in support of longitudinal MAID research and income as the project lead and working group chair of the Canadian Association of MAiD Assessors and Providers MAiD Curriculum project. Dr. Li has also received honoraria from Memorial Sloan Kettering Grand Rounds, Southlake Grand Rounds, Tulane University School of Medicine, and the Korean Psycho-Oncology Society, as well as payment for expert testimony in the case of Lamb v. Attorney General of Canada (all outside the submitted work). Dr. Li reports serving as Director of Medicine of the Board of Canadian Association of Psychosocial Oncology (CAPO) and Chair, Research Advisory Committee, CAPO (unpaid positions). No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: The June 2016 legalization of medical assistance in dying (MAiD) provided an added layer of choice to end-of-life care in Canada. Family caregivers play an important role in patient end-of-life decision-making. They may experience unique psychological burden or distress associated with their role. However, we know little about the caregiver experience associated with patient MAiD requests and the nature of psychosocial supports caregivers require before, during, and following MAiD intervention., Objective: The objective of this study is to better understand the caregiver experience of MAiD within the Canadian legal landscape following Bill C-14., Design: Caregiver experience was examined based on qualitative, semi-structured interviews., Participants: A total of 22 caregivers of patients who had requested MAiD were interviewed., Approach: Transcripts were recorded, transcribed, and analyzed based on grounded theory methodology., Key Results: The caregiver experience of MAiD within the legal framework was found to be understood as a "race to the end," with the ultimate goal of creating an ideal dying experience for the patient while balancing a threat to capacity that would undermine their access to MAiD. Caregivers can be described within the overarching framework as either co-runners or onlookers. Sources of caregiver distress were linked to these roles., Conclusions: The "race to the end" theoretical model contributes new knowledge and understanding that can inform the development of tailored support services for caregivers, the impact of legislative changes on this population, and future research examining decision-making near end of life and the caregiver experience., (© 2021. Society of General Internal Medicine.)

Objectives: The circumstances of advanced cancer heighten the need for affected individuals to communicate mortality-related concerns, although there may be obstacles to such communication. Managing Cancer and Living Meaningfully(CALM) is a supportive-expressive therapy designed to address such barriers and to facilitate communication of mortality-related concerns in patients and caregivers facing advanced disease. This study explores death-related distress in patients with advanced cancer and the perceived influence of CALM therapy on overcoming barriers to communication of this distress., Methods: Semistructured interviews were conducted with a subset of patients with advanced cancer (n=17) participating in a CALM phase III trial at a large urban regional cancer centre. Interviews were transcribed, and qualitative data were analysed using thematic analysis., Results: Death-related distress was experienced in terms of three key themes: diffuse and overwhelming fear, fear of uncertainty and fear of suffering. The perceived barriers to communicating such distress were as follows: reluctance of loved ones to discuss mortality-related issues and the participants´ own reluctance to discuss death-related concerns to protect their loved ones or themselves from distress. CALM therapists were perceived to facilitate discussions on dying and death in sessions and to support patients´ communication of death-related distress with healthcare providers and loved ones., Conclusions: Patients with advanced cancer perceive barriers to effective communication of death distress to be related to their own reluctance, as well as reluctance of their loved ones to address such fears. CALM therapy may help patients with advanced cancer to overcome obstacles to communication and to alleviate death-related distress., Trial Registration Number: NCT01506492., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2020. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: There has been increased awareness recently of the unique medical and psychosocial needs of adolescents and young adults (AYAs) with cancer. However, the existing AYA literature is mainly focused on curative disease or survivorship rather than on advanced disease. Using qualitative methodology, we sought to understand the experience of younger adults with advanced cancer., Methods: Participants were interviewed using open-ended, discovery-oriented interviews. Data was analyzed using thematic analysis. In total, ten English-speaking advanced cancer patients who were being treated at a comprehensive cancer center in Canada, were interviewed. Participants were between the ages of 18 and 35, and seven of them were female., Results: The diagnosis of cancer was universally experienced as isolating and unexpected, with serious illness regarded as a problem of older individuals. The core challenge of living in the face of dying was felt to be constantly present yet typically unarticulated. Meaning-making tended to be constructed around future-oriented goals rather than upon the life that had been lived. Individuals felt forcefully removed from the stream of life, with a perceived interruption in the developmental tasks of establishing adult identity, becoming autonomous, and forming new relationships. All cited a need for young adult-specific services, yet none could describe specific services that would be beneficial. Many expressed reluctance to engage in individual psychotherapeutic treatment., Conclusions: Advanced cancer in younger adults was perceived by them as isolating and as interfering with age-appropriate developmental tasks. Creative and flexible psychosocial support programs are needed to engage this population with limited expected survival.

Objective: The purpose of this article is to provide a brief review of the empirical literature regarding the impact of advanced cancer on the marital relationship. The link between attachment, caregiving, and care-receiving behaviors are defined. Both are activated and challenged in this population because the continuity of the marital bond is threatened, as well as the balance of reciprocal caregiving, often resulting in heightened marital distress., Methods: Emotionally focused therapy (EFT), based in a synthesis of systemic, experiential, and attachment theory, is introduced as a marital protocol to both conceptualize and potentially mitigate the level of increased marital distress, and to achieve reciprocal caregiving., Results: Two case studies are presented and support the benefit of EFT for those couples facing end of life., Significance of Results: The findings from these case reviews advance the literature and offer an empirically validated marital therapy for this population. Such a protocol that emphasizes attachment theory and the inherent link to caregiving and care receiving may serve as a powerful tool to both explain and alleviate marital distress for couples facing end of life. Working models of attachment can contribute significantly to our understanding of why individuals' distress and their experience of emotional support from spouse caregivers vary in the context of end-stage cancer.