Quality of care with telemedicine for medical assistance in dying eligibility assessments: a mixed-methods study
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* Stephanie Dion
* Ellen Wiebe
* Michaela Kelly

## Abstract

**Background:** To facilitate access to medical assistance in dying (MAiD) in British Columbia, telemedicine has been used for eligibility assessments. This research explored the impacts of using telemedicine on quality of care.

**Methods:** This mixed-methods study consisted of data from 3 BC health authorities and semistructured interviews with a patient, support persons, providers and administrators about the use of telemedicine for MAiD eligibility assessment. Interviews were conducted by telephone, video meeting or email between June and November 2018. We analyzed the quantitative data using descriptive statistics. We categorized the qualitative data using the 7 dimensions of the BC Health Quality Matrix and then analyzed them qualitatively with abductive coding.

**Results:** Twenty-one participants (8 MAiD assessors, 1 patient, 7 support persons of patients and 5 MAiD administrators) were interviewed. Telemedicine for MAiD eligibility assessments was highly acceptable to the support persons and patient and to most assessors and administrators. Assessors expressed challenges with empathy, eye contact, nonverbal communication and missing contextual factors. Participants described which patients were appropriate and which were not. Telemedicine improved access and equity for the patients who received this service. It was perceived as an effective and efficient way to perform eligibility assessments. Concerns were expressed by assessors and administrators, but not by the patient or support persons, about confidentiality. Opinions varied on the requirement for a regulated health care professional to be in physical attendance with the patient to act as a witness.

**Interpretation:** Quality of care can be achieved with telemedicine for MAiD eligibility assessments for specific situations and patients, and this modality has the potential to expand access to MAiD. Updated clinical and administrative policies are needed to address barriers to telemedicine access and to best support patients and assessors using this technology.

Medical assistance in dying (MAiD) “occurs when an authorized doctor or nurse practitioner provides or administers medication that intentionally brings about a person’s death, at that person’s request.”1 It has been legal in Canada since 2016. British Columbia has the highest proportion of medically assisted deaths in Canada, 2 but access is still problematic.3–5 To qualify for MAiD, patients must be in an advanced state of decline in capacity, with reasonably foreseeable natural death;6 they are rarely in a condition to travel. In BC, “one of the medical assessors, but not both, may provide their assessment by telemedicine provided that, during the telemedicine assessment, another regulated health professional is in physical attendance with the patient to act as a witness to the assessment.”7

Telemedicine use is expanding in BC;8 it has been used in other areas of medicine effectively to help improve access.9,10 In this research, we explored the impacts of using telemedicine for MAiD eligibility assessments on quality of care from the perspective of patients, support persons, assessors and administrators involved in the MAiD process in BC, addressing the question: Can quality of care be met with the use of telemedicine for MAiD eligibility assessments?

## Methods

### Setting and participants

This mixed-method study, which involved a convergent design, consisted of demographic and qualitative data obtained from semistructured interviews with patients, support persons, assessors and MAiD administrators who were involved with the use of telemedicine for MAiD eligibility assessments in BC. To assist with interpretation of the qualitative data, we obtained quantitative information on the proportion of telemedicine assessments by surveying BC health authorities. The survey was sent via email to MAiD coordinators at 5 geographic/local health authorities offering MAiD care coordination services in April 2019 (as of that date, the First Nations Health Authority did not offer MAiD care coordination services and was not included in the survey). All interviews were conducted between June and November 2018 by 1 researcher (S.D.) by telephone or video meeting (using GoToMeeting); participants wishing to answer questions via email were provided with that option. The interviews were audiorecorded and transcribed (M.K.), and any identifying features were removed. To recruit participants, we sent an invitation letter and a written consent form via email to contacts of a medical clinic providing MAiD services in Vancouver who had been involved with the use of telemedicine for an eligibility assessment. Participants provided verbal (audio-recorded) or written consent or both.

### Interview guide

The interview guide (Appendix 1, available at [www.cmajopen.ca/content/7/4/E721/suppl/DC1](http://www.cmajopen.ca/content/7/4/E721/suppl/DC1)) was developed with the BC Health Quality Matrix11 and included closed and open-ended questions. This framework, which comprises 7 dimensions of quality (Appendix 2, available at [www.cmajopen.ca/content/7/4/E721/suppl/DC1](http://www.cmajopen.ca/content/7/4/E721/suppl/DC1)), provides a common language for defining the quality of care and has been used by the BC Ministry of Health in setting priorities for the BC health care system.12 Participants were asked to provide insight about these dimensions according to their specific role and perspective. Experience with computers, the Internet and telemedicine was measured on a 5-point Likert scale from 1 (no experience) to 5 (highly experienced), and satisfaction with telemedicine was measured on a 5-point Likert scale from 1 (highly dissatisfied) to 5 (highly satisfied). Two researchers from the field (E.W. and M.K.) reviewed the interview guide and provided feedback to ensure content validity. An iterative process was used; questions evolved with time and new perspectives, and the interview guide was modified accordingly.

### Data analysis

We used Dedoose, a Web application for mixed-method research ([www.dedoose.com](http://www.dedoose.com)), to facilitate interview analysis. We analyzed the quantitative data using descriptive statistics and processed the qualitative data using principles of a phenomenology theoretical framework.13 We categorized the qualitative data using the 7 dimensions of the BC Health Quality Matrix14 and then analyzed them abductively, first looking at the whole and then coding for themes. Three researchers (S.D., M.K. [master’s candidates during the study] and E.W. [an experienced qualitative researcher]) met regularly to discuss coding and reach consensus on themes.

### Ethics approval

Approval was obtained from the University of British Columbia Behavioural Research Ethics Board.

## Results

Three BC health authorities provided data about the use of telemedicine for MAiD assessments (Table 1), a response rate of 50%. A total of 0.3%–5.7% of all assessments were done by telemedicine.

View this table:
[Table 1:](http://www.cmajopen.ca/content/7/4/E721/T1)

Table 1: 
Proportion of assessments of eligibility for medical assistance in dying performed via telemedicine for 3 British Columbia health authorities (as of April 2019)

Of the 24 people invited to participate, 21 (8 MAiD assessors, 1 patient, 7 support persons of patients and 5 MAiD administrators) (88%) consented. Fourteen of the 21 agreed to be interviewed by telephone and 4 by video-conference, and 3 preferred to provide answers via email. The average interview duration was 30 minutes.

Table 2 provides the participants’ demographic data, Table 3 provides an overview of their perception, experience and satisfaction regarding telemedicine, and Table 4 presents the types of devices, software and location used. Participants came from both urban or rural areas. The support persons and the patient had limited experience with telemedicine, whereas the assessors were somewhat experienced with telemedicine. A variety of devices and software were used for the consultations, which were conducted at home or through health authority telehealth facilities. Overall, participants expressed satisfaction with telemedicine; satisfaction was higher for support persons/patient and administrators than for assessors.

View this table:
[Table 2:](http://www.cmajopen.ca/content/7/4/E721/T2)

Table 2: 
Participant characteristics

View this table:
[Table 3:](http://www.cmajopen.ca/content/7/4/E721/T3)

Table 3: 
Experience, perception and satisfaction regarding telemedicine

View this table:
[Table 4:](http://www.cmajopen.ca/content/7/4/E721/T4)

Table 4: 
Devices, software and location for telemedicine

### Qualitative findings

The following dimensions provide a summary of the qualitative findings. Additional representative quotes are presented in Table 5.

View this table:
[Table 5:](http://www.cmajopen.ca/content/7/4/E721/T5)

Table 5: 
Representative quotes for each dimension of the BC Health Quality Matrix

#### Acceptability

The support persons and the patient thought that MAiD assessment via telemedicine was acceptable. Qualifiers included “easier,” “convenient,” “natural,” “patient centred,” “adequate,” “personal,” “helpful,” “fantastic” and “positive.” Assessors also expressed positive comments regarding telemedicine acceptability, despite conveying overall more reservation. One assessor stated that “the ability to touch, or the ability to move or see how [the patient is] moving is more difficult and limited, so empathy is reduced” (assessor F). Similarly, another assessor reported, “It’s not as warm and fuzzy as in person, but all the in person are not necessarily warm and fuzzy, either” (assessor G). Several participants thought that the context inherent to telemedicine assessments was not as rich or complete: “With telemedicine, I really just focus in on what their experience is with their illness or with their disease and less about them as a person, so I lose that aspect of knowing them” (assessor F). The administrators who acted as witnesses felt that their presence added a human touch to the consultation: *“*Sometimes I have been able to interpret what a physician has said on the phone … or also follow up with the patient about some of the conversations that happened on the phone*”* (administrator A).

#### Appropriateness

The support persons and the patient thought that using telemedicine was appropriate for their specific situation. For assessors and administrators, the appropriateness of telemedicine related to specific patient characteristics: *“*The patient needs to be able to use the technology appropriately, to be seen, to be visualized, to be heard, to make [him- or herself] understood*”* (assessor D). Another assessor stated, *“*In somebody who is alert and able to … very quickly and clearly provide consent, then I think telemedicine is fine*”* (assessor E). Two assessors expressed concerns about assessing frail patients via telemedicine.

#### Accessibility

Participants thought that telemedicine facilitated access to MAiD assessments for their loved ones because of their limited physical capacity: “I couldn’t have gotten him in the car, gotten him onto the ferry … that would have been really, really sad to have to do that” (support person C). In 2 instances, support persons believed that having the telemedicine option allowed access to MAiD because their loved ones were not able to travel for an in-person assessment: “It was her only way to find a doctor to do this, it was a miracle that Skype was available, it was wonderful” (support person A). Some assessors described telemedicine as facilitating MAiD assessments because of factors such as distance or underserviced areas. Two administrators thought that telemedicine increased access in a timely manner for the patients, highlighting that, even in larger population settings, access to in-person MAiD assessment was sometimes challenging.

#### Effectiveness

The support persons and patient thought that telemedicine was an effective way to conduct a MAiD assessment given their circumstances. Comments included “In that situation, it’s whatever works … and it worked” (support person C) and “It served the purpose that we were trying to achieve” (support person B). Most assessors had similar thoughts, concluding that they were able to reach their goals despite limitations inherent to telemedicine: “It gets the job done … and … at the end it is what it is right” (assessor G) and “It’s [not] as good as it can be in person but still good enough for me to do this work” (assessor D). Some assessors felt the need to expedite MAiD assessments via telemedicine owing to associated time limitations.

#### Safety

The support persons and patient did not express concerns related to safety in the context of telemedicine. For assessors, the recurring themes were privacy and confidentiality, especially when using their own device and software. Three administrators confirmed that their health authority recommended the use of a consent form for an assessment in which software that is not considered secure was used.

Three assessors doubted that the witness requirement had a meaningful impact on preventing coercion and felt that having a stranger in the room during the assessment was at times intrusive.

#### Efficiency

Support persons were adamant that telemedicine saved substantial travel time. One reported that telemedicine was also cost saving, given the travel cost of an in-person assessment. The assessors agreed that telemedicine assessments overall required less time, avoiding long-distance travel to assess a patient: “It allows the process in a timely fashion with … efficient utilization of physician and patient resources in the sense that it takes the travel away” (assessor G). Two administrators and 1 assessor thought that planning for telemedicine took longer than planning for an in-person assessment owing to the need to find and organize a witness. Several participants acknowledged that using telemedicine was cost saving from a system perspective, as the health authority did not have to reimburse travel fees for in-person assessments. Technologic issues rarely impeded the telemedicine consultations, but several assessors mentioned difficulty conducting an assessment when the patient had to be lying flat in bed: “The most important thing … is that I can see the patient, and sometimes it’s difficult if [he or she is] lying flat or — it’s quite difficult for [the patient] to see me, but I’m able to see [the patient]” (assessor C). Several participants thought that MAiD coordinators were instrumental in providing assistance and support for telemedicine.

#### Equity

Several participants pointed out that telemedicine allowed equitable access to MAiD assessment. One assessor noted, “Telemedicine can be the difference for allowing access to this care for certain people in certain areas” (assessor D).

## Interpretation

Findings from this research show that quality of care can be achieved through MAiD eligibility assessments via telemedicine for specific situations and patients. We found that the BC Health Quality Matrix was a useful framework to analyze quality of care in this situation. Overall, participants expressed satisfaction; satisfaction was higher for support persons, the patient and administrators than for assessors.

Acceptability was very high among support persons and the patient; this is an essential finding given the importance of a patient-centred practice. These results are similar to those of previous research on telemedicine consultations,15,16 which also showed high acceptability among patients. In the current study, the assessors expressed limitations in their ability to be empathetic via telemedicine and described challenges with the nonverbal communication and with losing contextual factors, which likely contributed to their lower level of satisfaction. This feeling was also discussed in research on providers’ perspective on telemedicine and abortion; inability to provide physical comfort to patients was reported as a limitation for the providers.17

Patient characteristics emerged as the main factor influencing telemedicine appropriateness. Most participants thought that, for a telemedicine assessment to be appropriate, the patient needed to be able to hear, see and speak, or communicate effectively and be proficient with the selected technology. Similar patient characteristics have been reported as being appropriate for telemedicine assessment in a previous study on telemedicine and abortion.17 Several assessors noted that frail people might be difficult to assess via telemedicine owing to limited or fluctuating capacity to meet those criteria, an important consideration given the notable proportion of frail patients requesting MAiD.5 The greatest degree of unanimity was observed for the accessibility dimension: participants expressed that telemedicine facilitated access to the assessment and even allowed access for some patients. Research on abortion18 and palliative care16 assessments via telemedicine also showed increased access to services when telemedicine was available.

Overall, participants agreed that using telemedicine was effective. The patient and support persons had no concerns about safety. Different perceptions on privacy regulations were voiced by assessors, which highlights the need to clarify standards of practice in this regard. Several participants agreed that telemedicine was efficient but that organizing a witness was a barrier to efficiency. The importance of the MAiD coordinators in providing operational support for the telemedicine consultation was emphasized, which shows that this recent policy was a positive initiative for the MAiD program in BC. Other studies showed increased efficiency with telemedicine,19–21 such as reduced overall cost for women for abortion consultation via telemedicine.19

As of April 2019, the use of telemedicine for MAiD eligibility assessments was relatively low in BC. Assessing and promoting the integration of a patient-centred virtual health model of service for the MAiD program in BC, with standard processes for access, consent and secure online platform, would be useful in harmonizing telemedicine practices and facilitating access to the service. We recommend clear mechanisms, such as consent forms, and communication between assessors and administrators to implement those mechanisms in order to enforce informed consent and protect patients. We need to know more about how patients and support persons perceive the witness requirement for telemedicine assessments. Another important area of research is specific outcomes related to telemedicine assessments that were outside the scope of this study. In particular, outcomes related to effectiveness, aside from participant satisfaction, should be investigated. Future research should also include the First Nations Health Authority given the remote or rural nature of some First Nations communities.

### Limitations

One limitation of this study is the small sample; data saturation was reached for some aspects in some groups, but not all. The sample was obtained with contacts from a single clinic, which increases the possibility of selection bias; however, participants came from various rural and urban areas of BC, which increases external validity. The interview guide was not validated with a wide sample of respondents. It is possible that the questions were not interpreted properly by the interviewees or did not provide a comprehensive approach to the topic. We used a Likert scale for specific questions such as participants’ satisfaction with telemedicine; answers to these questions should be interpreted with caution, as this method does not provide optimal internal consistency. We do not have data for the people who did not use telemedicine, apart from information on proportion. The perspective of support persons/patients regarding the witness requirement was not obtained for this research. Finally, this research did not include perspectives of First Nations people.

### Conclusion

This research showed that telemedicine can be used for MAiD eligibility assessments in a manner that is acceptable and effective for patients and assessors while improving efficiency of the program. Telemedicine has the potential to expand access to MAiD; this is of particular relevance given BC’s geographic context, assessor shortage and patients’ limited physical capacity to travel. Careful consideration of the risks and benefits of a MAiD eligibility assessment via telemedicine, on a case-by-case basis, is recommended to promote quality of care.

## Footnotes

*   **Competing interests:** None declared.

*   This article has been peer reviewed.

*   **Contributors:** Stephanie Dion and Ellen Wiebe conceived the study. All of the authors contributed to the study design, analyzed and interpreted the data, drafted the manuscript and revised it critically for important intellectual content, approved the final version to be published and agreed to be accountable for all aspects of the work.

*   **Supplemental information:** For reviewer comments and the original submission of this manuscript, please see [www.cmajopen.ca/content/7/4/E721/suppl/DC1](http://www.cmajopen.ca/content/7/4/E721/suppl/DC1).

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