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Previous Versions BMJ Open: first published as 10.1136/bmjopen-2019-036054 on 8 July 2020. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on September 27, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2019-036054 on 8 July 2020. Downloaded from The provision of medical assistance in dying: a scoping review Journal: BMJ Open ManuscriptFor ID peerbmjopen-2019-036054 review only Article Type: Original research Date Submitted by the 11-Dec-2019 Author: Complete List of Authors: Zworth, Max; McMaster University Michael G DeGroote School of Medicine, Saleh, Carol; McMaster University, Medicine; 1989 Ball, Ian; Western University, Division of Critical Care Medicine Kalles, Gaelen; Hamilton Health Sciences Chkaroubo, Anatoli; Hamilton Health Sciences Kekewich, Mike; Ottawa Hospital, Clinical and Organizational Ethics Miller, Paul; Hamilton Health Sciences, Emergency Medicine; McMaster University, Medicine (Emergency Medicine) Dees, Marianne; Radboudumc, Department for Primary and Community Care Frolic, Andrea; Hamilton Health Sciences, Clinical and Organizational Ethics http://bmjopen.bmj.com/ Oczkowski, Simon; McMaster University, Medicine (Critical Care); McMaster University, 8. Department of Health Research Methods, Evidence, and Impact PALLIATIVE CARE, Adult intensive & critical care < INTENSIVE & Keywords: CRITICAL CARE, Protocols & guidelines < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, MEDICAL ETHICS on September 27, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 757 BMJ Open 1 2 3 4 BMJ Open: first published as 10.1136/bmjopen-2019-036054 on 8 July 2020. Downloaded from 5 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the terms applicable for US Federal Government officers or employees acting as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author Forunless you peer are acting as review an employee on behalf only of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34 35 36 http://bmjopen.bmj.com/ 37 38 39 40 41 42 43 44 on September 27, 2021 by guest. Protected copyright. 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 757 BMJ Open: first published as 10.1136/bmjopen-2019-036054 on 8 July 2020. Downloaded from 1 2 3 The provision of medical assistance in dying: a scoping review 4 5 Max Zworth1, Carol Saleh2, Ian Ball MD3, Gaelen Kalles RN4, Anatoli Chkaroubo4, Mike Kekewich 6 7 5, Paul Miller4,6, Marianne Dees7, Andrea Frolic4, Simon J W Oczkowski MD2,4,8 8 9 10 11 Author affiliations 12 13 1. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada 14 2. Department of Medicine, McMaster University, Hamilton, Canada 15 16 3. Division of CriticalFor Care peer Medicine, Westernreview University, only London, Canada 17 18 4. Hamilton Health Sciences, Hamilton, Canada 19 20 5. Department of Clinical and Organizational Ethics, The Ottawa Hospital, Ottawa, Canada 21 22 6. Division of Emergency Medicine, Department of Medicine, McMaster 23 24 University, Hamilton, Canada 25 7. Department for Primary and Community Care, Radboud University Medical 26 27 Center, Nijmegen, The Netherlands 28 29 8. Department of Health Research Methods, Evidence, and Impact, McMaster University, 30 31 Hamilton, Canada 32 http://bmjopen.bmj.com/ 33 34 Corresponding author: 35 36 Max Zworth 37 38 Michael G. DeGroote School of Medicine, McMaster University 39 1280 Main Street West 40 Hamilton, ON, Canada, L8S 4L8 on September 27, 2021 by guest. Protected copyright. 41 [email protected] 42 43 44 Funding 45 This research is supported by a Hamilton Academic Health Sciences Organization’s innovation 46 fund. Dr. Oczkowski is supported by an internal career award from the Department of Medicine 47 at McMaster University. Max Zworth is supported by the McMaster Medical Student Research 48 49 Excellence Scholarship (MAC RES). 50 51 52 Tables: 4 53 Figures: 3 54 55 Word count: 2774 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 757 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2019-036054 on 8 July 2020. Downloaded from 1 2 3 Abstract (maximum 300 words) 4 5 Objectives: The purpose of this study is to map the characteristics of the existing medical 6 literature describing the medications, settings, participants and outcomes of medical assistance 7 8 in dying (MAID), in order to identify knowledge gaps and areas for future research. 9 10 Design: Scoping review 11 12 Search strategy: We searched electronic databases (MEDLINE, EmBASE, PsychINFO, CINAHL, 13 CENTRAL), clinical trial registries, conference abstracts, and professional guidelines from 14 jurisdictions where MAID is legal, up to June 2017. Eligible report types included technical 15 summaries, institutional policies, practice surveys, practice guidelines and clinical studies that 16 For peer review only 17 describe MAID provision in adults who have provided informed consent for MAID. 18 19 Results: 147 articles published between 1989 to 2017 met eligibility criteria. 72 studies 20 described details for MAID administered by IV medications, and 46 studies provided data on 21 22 oral medications. In IV protocols, MAID was most commonly administered using a barbiturate 23 (32/147) or propofol (20/147) followed by a neuromuscular blocker. Oral protocols most often 24 used barbiturates alone (36/147) or in conjunction with a neuromuscular blocker (13/147), and 25 often recommended using a prokinetic agent prior to lethal drug ingestion. Complications 26 27 included prolonged duration of the dying process, difficulty obtaining IV access, and difficulty 28 swallowing oral agents. Most commonly, the role of physicians was prescribing (71/147) and 29 administering medications (78/147). Nurses roles included administering medications (17/147) 30 and supporting the patient (14/147) or family (13/147). The role of families involved providing 31 support to the patient (15/147) and bringing mediations from pharmacy for self-administration 32 http://bmjopen.bmj.com/ 33 (4/147). 34 35 Conclusions: We identified several trends in MAID provision including common medications 36 and doses for oral and parenteral administration, roles of healthcare professionals and families, 37 38 and complications that may cause patient, family and provider distress. Future research should 39 aim to identify the medications, dosages, and administration techniques and procedures which 40 produce the most predictable outcomes and mitigate distress for those involved. on September 27, 2021 by guest. Protected copyright. 41 42 Key words: assisted dying, euthanasia, assisted suicide, physician assisted dying, scoping review 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 757 BMJ Open: first published as 10.1136/bmjopen-2019-036054 on 8 July 2020.
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