The factors that act as barriers and enablers to the implementation of voluntary assisted dying services in acute care health settings: a systematic mixed studies review and secondary analysis

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Jayne Hewitt
Sharon Latimer
Kristen Ranse
Jodie Deakin
Charles Lawson
Laurie Grealish


Voluntary assisted dying, implementation, acute care, hospital, mixed studies review, end-of-life care


Objective: To explore the barriers to, and enablers of, successful implementation of voluntary assisted dying into acute care health settings and identify the strategies that contribute to successful implementation in these settings. Background: In jurisdictions where voluntary assisted dying is legal, some people choose to end their lives in acute care health settings. How voluntary assisted dying is integrated as an end-of-life option for patients in these settings is an emerging area for implementation research. Study Design and Methods: A two-phase process was adopted. First, a systematic mixed studies review was undertaken to identify themes associated with the provision of voluntary assisted dying. The electronic databases ProQuest Central, Embase, and CINAHL including Medline were searched in June and July 2019. For inclusion, a study must have been published between 1997-2019 and undertaken in an acute care health setting in a jurisdiction where voluntary assisted dying is legally permitted. Study participants were those involved, directly or indirectly, with voluntary assisted dying. All studies were assessed for the risk of bias using the Mixed Methods Assessment Appraisal Tool. Data from the included articles were synthesised into descriptive themes. Themes were then deductively analysed using the Consolidated Framework for Implementation Research to identify possible barriers and enablers and generate strategies that support the implementation of voluntary assisted dying in acute care health settings. Results: Nine articles were included in the review. Seven articles were quantitative studies that collected cross-sectional survey data. There were two qualitative studies. Four themes were identified: 1) putting the law into practice requires knowledge and understanding gained through education, 2) helping people die using VAD is complex, 3) the how of enacting VAD, and 4) participating in voluntary assisted dying is deeply personal for clinicians. Barriers to implementation included: a lack of understanding of legal obligations associated with voluntary assisted dying and poorly defined roles. Enablers to implementation included: open and inclusive conversations about the process and building social capital through communities of practice. Discussion: The provision of voluntary assisted dying is multifactorial and complex. Its implementation in the acute care setting requires strategies built on an understanding of the enabling legislation and recognition of contextual and individual characteristics that contribute to its complexity.

What is already known about the topic?

  • Increasing numbers of jurisdictions worldwide are legalising voluntary assisted dying (VAD).

  • Some patients have a preference to be supported in VAD in an acute care health setting.

  • In jurisdictions where VAD is permitted, some acute care health settings have implemented structured programs to guide the practice of healthcare professionals.

  • There is limited research exploring how VAD is implemented in acute care health settings.

What this paper adds:

  • Clinician understanding of their legal and operational responsibilities is critical to address barriers to the implementation of VAD.

  • Education, policies, and procedures around VAD should be collaboratively developed by clinicians and legal-ethical experts.

  • Building social capital through a robust system of clinician support and reflection is required to continually improve the processes associated with VAD.

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