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Riding an elephant: A qualitative study of nurses' moral journeys in the context of Medical Assistance in Dying (MAiD)

Abstract Aims and objectives To describes nurses' moral experiences with Medical Assistance in Dying in the Canadian context. Background Nurses perform important roles in Medical Assistance in Dying in Canada and do so within a unique context in which Medical Assistance in Dying is provided through healthcare services and where accessibility is an important principle. International literature indicates that participating in Medical Assistance in Dying can be deeply impactful for nurses and requires a high degree of moral sense‐making. Design A qualitative interview study guided by Interpretive Description using the COREQ checklist. Results Fifty‐nine nurses from across Canada participated in the study. The decision to participate in Medical Assistance in Dying was influenced by family and community, professional experience and nurses' proximity to the act of Medical Assistance in Dying. Nurses described a range of deep and sometimes conflicting emotional reactions provoked by Medical Assistance in Dying. Nurses used a number of moral waypoints to make sense of their decision including patient choice, control and certainty; an understanding that it was not about the nurse; a commitment to staying with patients through suffering; consideration of moral consistency; issues related to the afterlife; and the peace and gratitude demonstrated by patients and families. Discussion The depth of nurses' intuitional moral responses and their need to make sense of these responses are consistent with Haidt's theory of moral experience in which individuals use reasoning primarily to explain their moral intuition and in which moral change occurs primarily through compassionate social interaction. Further, work on the moral identity of nursing provides robust explanation of how nurses' moral decisions are contextually and relationally mediated and how they seek to guard patient vulnerability, even at their own emotional cost. Conclusion Medical Assistance in Dying is impactful for nurses, and for some, it requires intensive and ongoing moral sense‐making. Relevance to clinical practice There is a need to provide support for nurses' moral deliberation and emotional well‐being in the context of Medical Assistance in Dying care.


legal in Canada.
Second, because the provinces and territories of Canada are responsible for healthcare, as a national framework Bill C-14 had to be contextualised for each unique jurisdiction. Third, as the provinces and territories are guided by the Canada Health Act (2018) in which a key guiding principle is accessibility, there has been a concerted effort to make MAiD accessible across healthcare services (Silvius, Memon, & Arain, 2019).
This unique Canadian context has practical implications for nursing. Guidelines and policies to support nurses vary in direction and specificity across provinces and territories (Pesut, Thorne, Stager, et al., 2019). Because MAiD is implemented through currently existing healthcare services, nurses encounter it in many practice contexts (e.g., medical units, palliative care, home care). Bill C-14 supports the right of nurses to conscientiously object to participation in MAiD. However, there is a tension between nurses' right to conscientiously object and patients' rights to MAiD access (Banner, Schiller, & Freeman, 2019).
In light of this unique Canadian landscape, and the central role of nursing in MAiD, our programme of research has sought to explore the policy, practice and ethical implications of MAiD for nursing. The purpose of this paper is to report on findings related to nurses' moral experiences in the context of MAiD from a qualitative interview study. This paper complements two other papers from the same set of interviews with 59 nurses in which we reported nurses' views on best practices and their experiences with health system issues .

| BACKG ROU N D
Several literature reviews have explored the implications of MAiD for nursing. A meta-synthesis of nurses' moral experiences with assisted death, conducted prior to the legalisation of MAiD, highlighted the sense of responsibility taken by nurses in an assisted death; the tensions nurses experienced when trying to alleviate suffering; the time-intensive role that nurses performed in negotiating inquiries around an assisted death; and the various ways in which nurses reconciled personal beliefs and professional obligations (Elmore, Wright, & Paradis, 2018). Another review of Canadian, Dutch and Belgian nurses' experiences with assisted death indicated that although nurses provided wrap-around care for patients and families considering this process, the assisted death itself was deeply impactful and produced an array of conflicting emotions (Pesut, Thorne, Greig, et al., 2019). Of particular interest in this review were Conclusion: Medical Assistance in Dying is impactful for nurses, and for some, it requires intensive and ongoing moral sense-making.

Relevance to clinical practice:
There is a need to provide support for nurses' moral deliberation and emotional well-being in the context of Medical Assistance in Dying care.

K E Y W O R D S
Canada, ethics, euthanasia, Interpretive Description, Medical Assistance in Dying (MAiD), moral, nursing, physician-assisted death, qualitative What does this paper contribute to the wider global community?
• This paper provides a nuanced description of the morally relevant factors that influence nurses' decision to participate in MAiD, nurses' emotional experiences with MAiD, and the moral reasoning nurses use to make sense of their participation, or nonparticipation.
• These findings will assist other countries to better prepare and support nurses in contexts where MAiD is legal or anticipated to become legal in the near future.
findings that moral sense-making in Canadian nurses was a dynamic process characterised by uncertainty and reflection (Beuthin, Bruce, & Scaia, 2018). Other reviews have focused more generally on the experiences of all healthcare providers but revealed similar findings of the emotional impact of MAiD (Fujioka, Mirza, McDonald, & Klinger, 2018) and the need for support and education for nursing, particularly in the ethical aspects of care and in conducting conversations around hastened death (Suva, Penney, & McPherson, 2019).
Recent qualitative studies have provided further evidence of nurses' experiences. A study of 26 Belgian nurses' experiences with euthanasia (Bellens, Debien, Claessens, Gastmans, & Dierckx de Casterle, 2019) revealed findings similar to an earlier study in the Belgian context (Denier, Dierckx de Casterle, De Bal, & Gastmans, 2010). Nurses experienced the euthanasia death as emotionally impactful. They took great responsibility in the provision of the best possible care and experienced this care as intensely rewarding if they were able to gain patients' confidence and fulfil their wishes. Difficulties were a result of ambiguous patient requests, poor teamwork, lack of time and the fact that nurses' supportive needs were often overlooked. The need for support for nurses, and particularly bereavement support, was also found in a recent Canadian study (Sheridan, 2017). Sheridan's study of nine palliative care nurses' experiences with MAiD indicated that support was required, in part, because some nurses were experiencing moral uncertainty. Another recent study in the Dutch context illustrated the importance of the assessment process to nurses' moral sense-making (Lewis, 2018). When these assessments were conducted with due care, and nurses were informed, they were more comfortable with the assisted death process. In relation to this moral sense-making, study authors reported that nurse participants were reluctant to speak of their opinions in relation to assisted death, though they described the process as "strange" and "never normal" (Lewis, 2018). An earlier study of Dutch nurses' experiences revealed similar findings of nurses' reluctance to share their opinions about assisted death out of a respect for one another (van de Scheur & van der Arend, 1998).
Finally, a recent study illustrated some of the challenges experienced by conscientiously objecting nurses in the Canadian context (Lamb, Babenko-Mould, Evans, Wong, & Kirkwood, 2019). Nurses found it difficult to take a stand against assisted death. When doing so, they felt alone, uncertain and stigmatised. Such findings of nurses' experiences have inherently moral underpinnings. However, no papers to date have focused on understanding the moral journeys of nurses involved, or choosing not to be involved, with MAiD in Canada.

| Design
This was a qualitative study using Interpretive Description, a pragmatic approach to qualitative research designed for applied disciplines (Thorne, 2016). The Consolidated Criteria for Reporting Qualitative Research were used to report the data (Tong, Sainsbury, & Craig, 2007; Appendix S1). Purposive and snowball sampling were used to recruit participants through health regions, the Canadian Nurses' Association, and the Canadian Association TA B L E 1 Legislative framework for MAiD in Canada (Bill C-14, 2016)  They have a serious and incurable illness, disease or disability They are in an advanced state of irreversible decline in capability That illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and Their natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining

Safeguards
Ensure that the persons' request for medical assistance in dying was (i) made in writing and signed and date by the person or another person and (ii) signed and dated after the person was informed by a medical practitioner or nurse practitioner that the person has a grievous and irremediable medical condition Be satisfied that the request was signed and dated by the person before two independent witnesses who then also signed and dated the request Ensure that the person has been informed that they may, at any time and in any manner, withdraw their request Ensure that another medical practitioner or nurse practitioner has provided a written opinion confirming that the person meets all the criteria; Be satisfied that they and the other medical practitioner are independent Ensure that there are at least 10 clear days between the day on which the request was signed and the day on which the medical assistance is provided (this may be shortened if the persons death or loss of capacity to give consent is imminent) Immediately before providing the medical assistance in dying, give the person an opportunity to withdraw their request and ensure that the person gives express consent If the person has difficulty communicating take all necessary measures to provide a reliable means of communication of MAiD Assessors and Providers. To be eligible to participate, nurses had to be registered nurses or nurse practitioners who had some experience with participating, or choosing not to participate, in MAiD. Interested participants contacted the research coordinator who then conducted a telephone or email conversation to explain the study and answer questions. After this conversation, a consent form was mailed. The interview was conducted after this signed consent was received, and participants had an opportunity to ask additional questions. Ethical approval was obtained through the Behavioural Research Ethics Board of the University of British Columbia.

| Data collection
Fifty-nine nurses were interviewed by telephone or in-person, by the principal investigator and/or research coordinator, using a semistructured interview guide that was piloted and revised prior to data collection. Interviews averaged 51 min in length with a range of 23-88 min. Interviews were digitally recorded, transcribed verbatim and downloaded into qualitative software nvivo for analysis. Field notes were written after each interview. Demographic data were collected for each participant (see Table 2). These participants had significant experience with MAiD.

| Analysis
Open codes were developed inductively by two research team members (BP and MG) after immersion in the first 6 interview transcripts.
Codes were further refined by two additional investigators (ST and JR) as data collection continued. Data were analysed using constant comparative analysis (Glaser & Strauss, 1967). Integrity of the analysis was supported through field notes, reflective memos, investigator triangulation and an audit trail. Transcripts were not returned for participant comments; instead, participants were invited to provide feedback after a webinar of the findings. Data collection was completed once the investigators had a coherent account of the nurses' experiences and questions that arose during the analysis had been answered.

| FINDING S
The following findings represent a variety of perspectives including those of registered nurses and nurse practitioners, those who have chosen to participate in MAiD and those who have not. To facilitate a more nuanced understanding of these diverse findings, where relevant, we identify participant characteristics (e.g., assessor/provider; conscientious objector). Further, to protect the anonymity of the small number of male participants, we will refer to all participants as female. Understanding nurses' moral journeys entailed understanding why nurses became involved, or chose not to be involved, in MAiD, how they experienced MAiD, and how they made sense of those experiences (see Table 3).

| Willingness to participate in MAiD: Morally relevant factors
As part of the interview process, we asked nurses to reflect on what influenced their initial decision to participate, or not, in MAiD. This decision was shaped by family and community influences, professional experience and their proximity to the act of MAiD.

| Family and community influences
Family support was essential for nurses to consider when deciding whether or not to participate in MAiD. Participants considered part-

| Professional experiences
The professional experiences that impacted nurses' decision to participate in MAiD included influential colleagues, clinical experiences with suffering, and commitments to personal and professional values. Colleagues were a source of moral influence when deciding whether to participate in MAiD. As this nurse practitioner, who acted as an assessor, suggested, it was her colleagues that finally helped her to make the tough decision: I've spoken to a number of clinicians who are much more experienced at this than I am and said to them, Nurses further talked about their commitments to professional values. Those who were palliative care nurses spoke of the palliative philosophy of neither hastening nor postponing death. Older nurses spoke to the commitments that had guided their dedication to nursing and to healthcare. The socialisation that older nurses had experienced to be good employees and team players made it difficult to say no when there were not enough providers to make MAiD accessible.
As one participant described it, she was socialised as a nurse to be obedient, respectful and to put her workplace first. When her manager asked her to participate in one of the first MAiD cases she said, I didn't want to disappoint her. I'm going to really rise to the occasion and not disappoint (P37). However, after assisting with a number of patients she had taken a step back, "It's taken a toll on me and I don't know why" (P37).
Other nurses described how MAiD in the Canadian context provided a unique opportunity for nursing as a profession. One nurse described MAiD as a ground-breaking area of nurse practitioner practice. Not only were they the only nurses in the world authorised to assess for and provide MAiD, but for many, it was a rare sphere of nurse practitioner practice that was entirely independent of physician oversight. As such, it was viewed as a practice that could make a significant difference both for the profession of nursing and for patients by filling the gap associated with insufficient numbers of physicians willing and able to provide MAiD.

| Proximity to the act of MAiD
Finally, participants' decisions to participate in MAiD were influenced by their proximity to the act of administering the medications. They might agree with MAiD in theory, and in particular, the right of patients to make that choice, but that did not mean they

| Experiences of MAiD
Early decisions to participate were further influenced by nurses' ongoing experiences with MAiD. Those experiences allowed them to reflect further on their positioning, sometimes with unpredictable results. Nurses described a range of emotions that MAiD provoked and attributed those emotions to various factors.

| Emotional experiences
For some nurses, experiencing a MAiD death was emotionally impactful in a positive sense and thus reassured them about the moral goodness of MAiD. Adjectives such as profound, amazing and humbling were used to describe the transformative effect this experience could have on them. One participant likened it to entering the final frontier of a Star Trek episode-simply "mind boggling" (P27). Another participant, a MAiD provider, explained how during the provision she experienced an overwhelming feeling of kindness, and a confidence that this was the right thing to do. However, the impact was not always positive. One provider described the last poignant moments of a family together and its effect on her. For conscientious objectors, experiencing a MAiD death vicariously could result in a sadness that overshadowed their work-life.
One participant described how she had naively believed that being a conscientious objector would limit her emotional involvement. But, because of her commitment to engaging with patients and families as they walked through the process, she too experienced an emotional impact. "I've removed myself from participating in MAiD but it certainly doesn't remove you from being affected emotionally" (P34).

| Attributions
The emotional impact described by nurses was attributed to various factors. For example, the palliative care nurse who experienced the emotional overload described above, said, "because even though It is important to re-emphasise that there was considerable variation across the data set in terms of participants' emotional reactions. Some described MAiD as among the most profound and rewarding of their experiences in nursing; others experienced it with a sense of sadness, despair and disbelief. What was common in these accounts, however, was how MAiD could change nurses' lives and careers. Some nurses described it as the highest privilege and some of the most meaningful work they had ever done. "It's now become some of the most powerful palliative experiences I have ever had" (P2).
Others had chosen to change jobs or to retire from nursing entirely because of how MAiD had changed the care landscape. This was the case if MAiD became part of their employment responsibilities and subsequently influenced their ability to provide continuity of care (e.g., palliative nurse clinicians).

| Moral waypoints
Even as participants experienced uncertainty around this new end of life option, they reflected on moral waypoints that revealed their moral compass, and hence, helped them make sense of their experiences. These moral waypoints were different than their initial reasons for involvement for they represented nurses' ongoing reflections as they experienced the impact of their initial choices to be involved or not. "I am a Buddhist so it was a struggle for me to decide. Everybody's arguing for religious reasons but I felt I needed to explore it a bit more. So, I thought, let's just get involved and see if that makes any difference" (P4).
In many cases, the same waypoints were used by those who decided to participate and those who chose not to participate in MAiD.
They were simply interpreted differently. These waypoints included patient choice, control and certainty; an understanding that it was not about the nurse; a commitment to staying with patients through suffering; consideration of moral consistency; issues related to the afterlife; and the peace and gratitude demonstrated by patients and families.

| Patient choice, control and certainty
In reasoning through the moral complexities of MAiD, a frequent waypoint was that MAiD provided patients with choice, control and some degree of certainty. "I'm doing something that I believe very, very strongly in and it's totally at the request of that individual lying there" (P29). This assumption of the importance of choice and control was so compelling that it could be difficult for participants to understand why some questioned the moral rightness of MAiD. For example, this MAiD assessor and provider stated, "the ability to have choice and control is an empowering gift. There is no reason to make people suffer unnecessarily.

It's just common sense and I don't understand why it is so controversial"
(P25). Participants recognised that patients gained this control irrespective of whether they chose to complete MAiD. Knowing that they were eligible, and that they could receive MAiD if their dying trajectory became too difficult, was in itself empowering for patients.
This patient control was important because of the perception that the healthcare system all too often takes control of the lives of patients.
"We take a lot of responsibility away from patients and put a lot of control on them" (P20). Participants acknowledged that, even without MAiD, patients will take control of their dying. They shared stories of patients in their care who had tried to commit suicide, sometimes with horrific results. In light of such experiences, one assessor suggested that MAiD provided a "civilized, respectful, and dignified" (P13) alternative for those who were determined to control their own deaths.
Alongside choice and control was the assumption that "patients know themselves best" (P38

| Moral consistency
Another way in which nurses grappled with the moral complexities of MAiD was to compare it to other morally contentious issues. For example, one participant who worked as an assessor described how she was adamantly opposed to MAiD initially but then changed her mind after reflecting on her position in relation to abortion. She decided that it all came down to the importance of personal choice (P50).
Palliative sedation was another reference point for moral equivalency. One participant spoke of how this was a natural extension of the palliative sedation process, in that patient autonomy is removed, and so there was really little difference (P24). Another participant had seen palliative sedation go very wrong, and so decided that MAiD was actually the more compassionate choice (P27). Moral distinctions between removing life support and MAiD were also considered. "I don't think practitioners who remove someone from life support consider themselves to be killing someone either" (P30). The difference between clinician-administration and self-administration of the medication was also cited. This participant, who was a provider, suggested that self-administration might ease the process for the nurse psychologically, but at the end of the day they were still accountable for their

| Reflections on the afterlife
The mysteriousness of the soul, and of death, was a waypoint for

| Peace and gratitude
One of the strongest waypoints for participants was how peaceful the MAiD death was and how grateful patients and families were for their assistance. Indeed, quick and peaceful were two of the most common adjectives used to describe a MAiD death. As one participant who was a provider suggested, it is the peacefulness that helps her get through the process.
Similar to the experience of the peaceful death, participants spoke of the gratitude they received from patients and families. "Every patient I've ever encountered has expressed and been truly grateful they have the opportunity to do this" (P20). One participant, who had been present at over 50 MAiD deaths, reflected on how she still gets emotional but how gratitude eases that emotion: The patients always say that they're grateful that their suffering is going to be over and the family members, whether they agree with the care option or not, because a lot of family members think this is awful, even after the assisted death has happened, the family members usually say, I'm happy that their suffering's over.
A nurse practitioner, who was an assessor, had a similar experience with a family member who was both conflicted and grateful at the same time. Prior to thanking her, the family member inquired how she was able to do this and said, "'you guys are kind of like executioners' and I was like, Oh My God. I have not been able to shake that out of my brain." (P01) Another provider reflected a similar experience. "They all seem so grateful when we come [to provide MAiD]. We try to get consent from them and all they'll say is, 'Yes, I'm ready. You know, I've been waiting for this and, you know, this is my day'"(P30). The gratitude was a reward that offset some of the challenges of a MAiD death. "When you get a warm and fuzzy from somebody or a hug from a family member. That's a reward in itself" (P14).

| D ISCUSS I ON
The moral journey of making sense of MAiD was often a complex and arduous one. Participants described a moral intuition deeply shaped by personal, social and professional experiences. This intuition was further shaped by reflections, conversations and direct experiences with a MAiD death. Participants used reasoning tactics as waypoints that helped them think through the moral complexity of MAiD. Nurses in this study illustrated a diversity of experiences as they sought to build a level of moral comfort with their decision to participate, or not, and their subsequent care of patients. In this discussion, the work of Jonathan Haidt (2001Haidt ( , 2012, psychologist and moral philosopher, and work on the moral identity of nursing, may provide possible theoretical explanations for such diverse findings. Haidt (2012) uses the analogy of a rider and an elephant to describe moral experience. Drawing upon a robust body of evidence within psychology, he suggests that moral judgement is made up of two types of cognition: intuition and reason. The intuitive aspect of cognition relies heavily upon emotion, and this emotional experience is so primal and influential that he likens it to an elephant. Further, he argues that the reasoning aspect of cognition is typically used to justify these moral intuitions in a post hoc sense. Reasoning becomes the rider that seeks to control (explain) the powerful intuitional elephant. As such, moral intuitions are difficult to change, at least through argument and reason.
They change primarily through engagements with others that are characterised by empathy, warmth, respect and openness.
This analogy of the rider and the elephant provides an interesting framework through which to view the interplay between nurses' emotional experiences and their subsequent professional reasoning and judgement. The emotional impact of MAiD on nurses described in many studies, the variability and enduring nature of nurses' responses, and the life-changing impact fits well with the analogy of the moral intuitional elephant. The magnitude of nurses' emotional responses and the difficulty they had in explaining those responses, even if they believed they were doing something good, suggested a deep intuitional process. In contrast, the rider in this data set represents the many moral reasoning waypoints that nurses used to make sense of their journey. Whether these reasons were related to patient control, selflessness, suffering, moral comparisons, the afterlife or patient impact, they all functioned as a means of providing a form of reasoning through which to try to make sense of both their moral experiences and their moral stance in relation to MAiD. Haidt's (2012) argument that our moral intuitions are largely shaped through social interaction is echoed by Doane's (2002)  Further, a commitment to guarding patient vulnerability was evident across the moral divide of MAiD proponents and conscientious objectors. Proponents of MAiD believed they were making a profound difference by protecting the autonomy of patients to control vulnerability. Conscientious objectors believed they were making a difference by providing compassionate care through the process of vulnerability. Nurses on both sides were profoundly committed to making a difference amidst the realities of the dying process. The only difference was in how they chose to address that vulnerability. On both sides of this apparent divide, nurses reflected on the mystery of life, death and suffering, and how difficult it was to really know right action in the face of such mystery.

| Limitations
Although this was a purposive sample in the sense that these participants could richly inform our findings because of their experiences, it was also a convenience sample. It is likely that those who had been most impacted were also the most likely to contact us to participate.
The depth of emotion evident in these interviews would support this. The use of telephone interviews may also have limitations with such a sensitive topic. However, participants were so forthcoming with their experiences that it is possible that the telephone provided a necessary anonymity. Further, we chose to analyse these diverse experiences together, while paying attention to relevant factors such as role, decision to participate or not, and geographic context. Our findings not only illustrate that complexity, but also demonstrate that a deeper understanding could be gained by studying the common experiences within these subgroups of participants (e.g., rural nurses; conscientious objectors; assessors/providers).

| CON CLUS ION
Nurses in this study provided an intimate look at what influenced their decision to participate in MAiD, or not, and their moral sensemaking as they incorporated that decision into the care context.
These findings support a growing body of literature that attests to the importance of the nursing role in high-quality assisted death care, and the impact such care can have on the lives and careers of nurses. The moral identity of nursing, which directs nurses to guard the vulnerabilities of patients, means that nurses take great responsibility in ensuring the best death possible, and hence, experience the moral weight of such involvement in what remains a morally contentious act.

| RELE VAN CE TO CLINI C AL PR AC TI CE
There is a need to better support nurses' moral journeys in clinical practice. Nurses in this study experienced the impactful nature of MAiD while holding to the nursing moral identity that it was about patients and "not about them." The combination of a morally difficult act, a deep commitment to vulnerable patients and the sublimation of nurses' experiences is a perfect storm for moral distress.
Facilitating the compassionate conversations identified by Haidt (2012), and considering the type of moral community that would support such conversations, is an important step to supporting nurses. Liaschenko and Peter (2016) have suggested that such com-

ACK N OWLED G EM ENTS
We are grateful to the nursing participants who shared their stories with us in such great detail and sometimes at great cost.

CO N FLI C T O F I NTE R E S T
Authors have no conflict of interest to declare.

AUTH O R S CO NTR I B UTI O N S
BP, ST, JS, KC, MG and MB made substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data, were involved in drafting the manuscript or revising it critically for important intellectual content, gave final approval of this version to be published and agree to be accountable for all aspects of the work.