Dr. Edward Mathews:

I thank the Chair. The Irish Nurses and Midwives Organisation represents 45,000 registered nurses and midwives in Ireland. We represent the vast majority of nurses and midwives engaged in both public and private practice in the Irish healthcare system. We want to thank the committee for facilitating our contribution on these important issues.

Assisted dying is a highly contentious and much debated topic, both in the public domain and in nursing and midwifery arenas. Research in international nursing literature in this area discloses perspectives on this issue which have been raised regarding compassion, poor management of uncontrolled pain or other symptoms, patient autonomy, care provider autonomy, the potential for coercion and abuse and the vulnerability of people with disabilities in care. Ultimately, this debate, as members of this committee will no doubt be aware, is very complex, involving many varying legal, ethical, medical, sociocultural, and religious issues and views.

As an organisation as a whole, we take a neutral stance in relation to whether there should be a change in the law in this area. However, what is clear from the experience of all other jurisdictions is that where there has been a change in the law to allow assisted dying, there are significant implications for nursing practice which must be considered in four areas, which are from legislative, regulatory, professional practice, and employment perspectives for our members.

I mention first the issue of palliative care. Whatever decision is ultimately made by the Legislature in this area, the importance of palliative care must not be underestimated. The need to improve, expand and ensure access to appropriate palliative care services is something recommended in all discussions around assisted dying. It is recognised that difficult conversations revolve around and are central to the provision of high quality palliative and end of life care. However, we must retain the distinction between therapeutic end of life decisions as part of palliative and end of life care on one hand and assisted dying on the other. As members will see in our submission, which, in the interests of time, I know they will have an opportunity to read, it is important to recognise the deficits and unmet needs which have existed and to ensure improved services, increased investment, improved nurse staffing levels, and to maximise nurse-led services in this area to increase accessibility across all of Ireland.

There are of course specific issues which arise for nurses and midwives. I recognise the submission of my colleagues in the college. There is no doubt that, while it is a slightly different context, very similar issues arise for nurses and midwives in many respects. Research shows that in all jurisdictions which have introduced legislative changes to facilitate access to assisted dying, and this might not be something that has been appreciated to date, nurses are likely to be the first point of contact for patients making requests for information about assisted dying services. Therefore, the impact of any change in the law on nursing practice requires careful consideration and consequent planning and clear interventions to avoid interference with the quality of care a person can expect, and to protect healthcare professionals as well.

Drawing on experiences internationally, I turn firstly to legislation.

There are deeply held views from a personal, moral, ethical and religious viewpoint in this area, and the right of nurses to conscientiously object to participating in care associated with assisted dying must be protected. This right is currently protected under the NMBI code of professional conduct and ethics for nurses and midwives. Should a legislative change be recommended in this area, it is also important that such protections are reflected in legislation.

The committee is also asked to consider what role advanced nurse practitioners may play if there is a change of law in this area. It is an area that has been under-explored in other jurisdictions that have changed the law, and has led to certain issues emerging about what the role should or should not be in that area. If there is to be a legislative change, it is also very important that either in the context of the legislation, and-or in the context of regulatory advice, the intersections between assisted dying and both assisted decision-making and advanced healthcare directives are adequately addressed. Failure to do so in other jurisdictions has led to unintended consequences which have in some instances increased suffering and also increased difficulties for professionals.

There is a requirement for regulatory change. In the interest of time, I will simply note that the current code of professional conduct and ethics for nurses and midwives, on one reading, would be entirely inimical to the provision of assisted dying services. That is not the only reading that is available, but regulatory changes would be required. As well as changing the code of professional conduct for nurses and midwives, there would be a requirement for very clear regulatory guidance to make sure that nurses and midwives are clear on exactly what is permitted and what is not permitted in particular contexts. That is necessary to protect the professionals, but to be fair, if it were to be decided by society that there should be the change in service provision in this area, then it would be necessary to protect that service provision and ensure its efficiency as well.

From a professional practice and employment point of view, it is absolutely essential that there are clear policy and procedural guidelines. It is essential that professionals are provided with education and training in the areas where change will occur. It is necessary that there is a robust ongoing professional supervision. It is also necessary to recognise that nurses are often profoundly impacted by either discussing assisted dying or participating in the provision of assisted dying services, and consequently, they are the most likely persons to be first consulted and to have the highest exposure to patient suffering over a 24-7 cycle. Therefore, we must provide personal support, including debriefing sessions. We must respect those who have a conscientious objection, legislatively and from a regulatory perspective, and assist persons to explore if they have an objection.

In conclusion, arising from the very many, varied and complex issues and views involved in this issue, we take a neutral stance in relation to whether there should be a legislative change. However, if there is to be a legislative change it will be important, from the perspective of protecting professionals and also the public who expect a certain level of service, that there is adequate planning and provision made from a legislative, regulatory, professional practice and employment perspective.