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Abstract
Background Medical assistance in dying (MAiD) traverses challenging and emotionally overwhelming territories: healthcare providers (HCPs) across jurisdictions experience myriad of affective responses secondary to possible tensions between normative and interwoven values, such as sanctity of life, dignity in death and dying and duty to care.
Objective To determine the emotional impact on HCPs involved in MAiD.
Methods Inclusion restricted to English language qualitative research studies from four databases (OVID Medline, EMBASE, CINAHL and Scopus), from beginning until 30 April 2021, and grey literature up to August 2021 were searched. Key author, citation and reference searches were undertaken. We excluded studies without rigorous qualitative research methodology. Included studies were critically appraised using the Joanna Briggs Institute’s critical appraisal tool. Analysis was conducted using thematic meta-synthesis. The cumulative evidence was assessed for confidence using the Confidence in the Evidence from Reviews of Qualitative Research approach.
Results The search identified 4522 papers. Data from 35 studies (393 physicians, 169 nurses, 53 social workers, 22 allied healthcare professionals) employing diverse qualitative research methodologies from five countries were coded and analysed. The thematic meta-synthesis showed three descriptive emotional themes: (1) polarised emotions including moral distress (n=153), (2) reflective emotions with MAiD as a ‘sense-making process’ (n=251), and (3) professional value-driven emotions (n=352).
Discussion This research attempts to answer the question, ‘what it means at an emotional level’, for a MAiD practitioner. Legislation allowing MAiD for terminal illness only influences the emotional impact: MAiD practitioners under this essential criterion experience more polarised emotions, whereas those practising in jurisdictions with greater emphasis on allaying intolerable suffering experience more reflective emotions. MAiD practitioner’s professional values and their degree of engagement influence the emotional impact, which may help structure future support networks. English language literature restriction and absence of subgroup analyses limit the generalisability of results.
- medical ethics
- medical law
- international health services
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. Data set 'Codes and themes-qualitative analysis_MAiD_HCP_emotional impact' submitted and published at ZENODO and is available at DOI: 10.5281/zenodo.6778236. No unpublished data.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
An eligibility criteria and subsequent search strategy that focuses on emotional impact of medical assistance in dying (MAiD) on healthcare providers (HCPs) with qualitative research methodology.
Use of Joanna Briggs Institute’s critical appraisal tool for assessment of risk of bias and use of the Confidence in the Evidence from Reviews of Qualitative Research approach for assessing the methodological limitations, relevance, coherence and adequacy of the evidence after completion of meta-synthesis.
Qualitative signals of absence of subgroup analysis, eligibility criteria limited to published English language literature and fast-moving pace of research on emotional impact of MAiD on HCPs likely contribute to significant publication bias.
Generalisability of evidence limited by presence of selection bias in included studies.
Introduction
Medical assistance in dying (MAiD) poses ethically complex challenges that can be a major source of distress to participating healthcare providers (HCPs)—especially since MAiD may involve navigating conflicting personal and professional values. These values are contextual, dynamic and often not in alignment with each other; for example, professional values of duty to care and reducing suffering in case of terminal illness through MAiD may conflict with the moral value of preserving sanctity of human life, as the later may involve forbidding any action that hastens a patient’s death in the dying process.1 2 In the context of assisted death, an HCP often has to navigate value conflicts between respect for autonomy and patient’s right to self-determination versus respect for individual human life, and human life in general. Except for Switzerland, all other countries require HCPs to be at the forefront in discussing and executing eligible requests for assisted death within their defined jurisdictions.3
Assisted death in selected jurisdictions: overview and current status
The number of jurisdictions across the world with medically assisted death legislation continues to grow. Switzerland, Netherlands, Belgium, Luxembourg, Canada, besides jurisdictions in the USA (Oregon, Vermont, California, Washington State, Colorado, the District of Columbia, Hawaii, Maine and New Jersey) alongside the states of Victoria, Tasmania and South Australia in Australia and Columbia in South America, and most recently Spain and New Zealand, have legalised medically assisted death in some form.3 4 Assisted death legislations in Canada, the State of Victoria in Australia and the Benelux countries include both assisted suicide and euthanasia. Jurisdictions in the USA and Switzerland allow only assisted suicide.
Broadly speaking, the ‘Benelux’ countries (Belgium, Netherlands and Luxembourg) have less restrictive rules in place for MAiD than the American jurisdictions that permit this practice. For example, Benelux countries allow advanced directives, and terminal of illness is not a requirement for MAiD eligibility in Belgium and Netherlands. Jurisdictions in the USA, on the other end, have strict eligibility criteria that the illness must be terminal and there must be some timeline to foreseeability of natural death—commonly 6 months in most jurisdictions.
Intact decision-making capacity translating to ability to give informed consent for MAiD, voluntariness of request and suffering from a terminal illness are the mainstay of the eligibility criteria for MAiD, with each criterion receiving variable emphasis, depending on the legislative jurisdiction. For example, ‘reasonable foreseeability of natural death’ criterion was removed from Canada’s MAiD eligibility criteria following recent changes in the legislation.5–8
HCPs and MAiD: current knowledge and knowledge gaps
From an ethics perspective, among the HCPs, the physician’s role in providing MAiD is perhaps the most ambiguous. Historically, medicine as a profession is rooted in the ethical principle of ‘first, do no harm’ while providing care. While this is true, medical futility and the sense of powerlessness and loss of control at end of life are a reality in modern medical practice, which is often reflected as physician ambivalence to participate in MAiD.9–11
While this sense of moral ambiguity may distance physicians from the practice of MAiD, nurses also share the complex attitudes and polarised feelings towards MAiD.12 This complexity is often due to the dual role that nurses play in most healthcare systems around the world: on one end, they act as a strong advocate for patient’s wishes, whereas on the other end, they only have a supportive role in medical decision-making process. A recent synthesis of qualitative studies describing registered nurses’ experiences with MAiD from Belgium, Netherlands and Canada showed that while the nurses played a central role in providing important ‘wrap-around’ care for patients and family, their participation in MAiD required significant moral work.13
A recent scoping review exploring the challenges faced by HCPs while handling MAiD requests found lack of clear guidelines/protocols, role ambiguity, difficulties in evaluating capacity/consent, conscientious objection, lack of interprofessional collaboration and difficulties in assessing nature and severity of suffering as major barriers in developing comprehensive care models for implementation of MAiD.14 Furthermore, the scoping review also pointed out that HCPs need substantial degree of time and emotional commitment to participate in a MAiD request. A scoping review and thematic meta-synthesis of qualitative studies exploring HCPs’ attitudes towards assisted death practices in Belgium, Netherlands, Israel, Australia, Germany and the USA showed that their attitudes were shaped by a deep sense of moral responsibility and contextual care relationships.15
This empirical evidence provides valuable insights on experiences and attitudes of HCPs towards MAiD; however, the nature and extent of emotional impact remains unexplored. Preliminary evidence suggests that the shift away from the medicine’s fundamental values of cure/control of disease to hastening death with the aim of alleviating intolerable suffering can have significant emotional effects on participating HCPs. These can range from feeling overwhelmed with a sense of powerlessness on one end, to a rewarding and a positive experience on the other.16 17
Objectives
To determine the emotional impact on HCPs involved in MAiD.
Methods
Search strategy, screening and eligibility criteria
The inclusion and exclusion criteria were developed in line with the Sample, Phenomenon of Interest, Design, Evaluation, Research type.18 In order to ensure qualitative richness of themes, we included all qualitative research studies and excluded surveys, personal anecdotes, attitudes and experiences without in-depth qualitative analysis published on this topic.
Relevant definitions
For the sake of this review, we define an HCP as a person ‘lawfully entitled under the law of a province to provide health services in the place in which the services are provided by that person’.19 This definition includes pharmacists, nurses, nurse practitioners, social workers, spiritual health practitioners, psychotherapists and clinical psychologists who are legally authorised to practise within their respective scope of practice. We included ‘Assisted suicide assistant’ and provider in ‘Right to die’ societies in Switzerland as unique MAiD care providers who contact the eligible participant and liaise with the physician and pharmacist in the conduct of MAiD.
For the sake of this review, the term ‘MAiD’ refers to20:
The administering by a physician or nurse practitioner of a substance to a person, at their request, that causes their death (euthanasia).
The prescribing or providing by a physician or nurse practitioner of a substance to a person at their request, so that they may self-administer the substance and, in doing so, cause their own death (assisted suicide).
Eligibility criteria
Includes worldwide published literature on the research question in English language, inclusive of all age groups; articles published up to 30 April 2021.
Includes all qualitative studies evaluating the emotional impact through qualitative research methodologies like grounded theory, semistructure interviews, narrative inquiry or others, and describes/mentions:
‘HCPs’ and ‘MAiD’ as defined above.
The emotional impact on HCPs in terms of emotions/affective responses experienced or expressed while accessing, discussing, participating or caring for the patient who has made a valid MAiD request.
Excludes case studies, anecdotes or studies without a description or mention of a rigorous qualitative research methodology.
Search strategy
An iteratively developed search strategy was developed and piloted with the help of three librarians with expertise in systematic review search strategies. Considering the interdisciplinary nature of the objective, the search strategy was conducted on OVID Medline, CINAHL, EMBASE and Scopus databases. The search terms included three main domains—MAiD, HCPs and qualitative research methodology and their synonyms. Full search strategy on the four databases is available in online supplemental appendix 1.
Supplemental material
In addition to database searches, the study team conducted a grey literature search21 which was informed by search methods outlined by Godin et al,22 using the same search terms and their synonyms. Grey literature was retrieved between 10 December 2018 and 1 March 2019, and updated on 10 August 2020, and 10 August 2021, from:
Databases including Google Scholar, the Canadian Electronic Library and the Canadian Institute for Health Information.
OpenGrey, Bielefeld Academic Search Engine and the OAIster catalogue of open access resources that includes digital thesis sources like the WorldCat.
The grey literature search strategy and results are included in online supplemental appendix 1. For the purpose of feasibility, reports from the year 2000 and beyond were retrieved. In addition, backward citation tracking was conducted by hand searching the reference lists of all included papers.
Study selection process
All identified records were imported into the reference management software, Zotero, and duplicates removed by the lead researcher (SYD). Twenty per cent of the titles and abstracts of peer-reviewed records were independently screened by two reviewers (AS and AB) based on the eligibility criteria; SYD screened the remaining 80% for eligibility and reviewed the results with AS and AB in regular team meetings. Given that a substantial portion of grey literature did not include abstracts, the grey literature screening process was initiated at the full-text phase. SYD consulted the keywords of yielded academic records if the title and abstract lacked clarity in relation to core concepts and reviewers AB and AS independently assessed any records for any discrepancy and/or uncertainty regarding their inclusion. The researchers met at the beginning, middle and end of the screening process to ensure consistency. SYD, AS and AB independently screened the full texts of the academic and grey literature, applying the same inclusion and exclusion criteria in successive team meetings to resolve any discrepancies.
Patient and public involvement
No patients were involved.
Assessment of risk of bias
We used the Joanna Briggs Institute’s critical appraisal tool for use in systematic reviews: checklist for qualitative research to critically appraise the included studies over 10 constructs. These constructs range from congruency to philosophical construct to theoretical and cultural location of the researcher.23 The results of the assessment of risk of bias were independently reviewed by AB and AS and are presented in detail in online supplemental appendix 2.
Supplemental material
The search results and reasons for exclusion at each stage of screening were recorded and represented in the adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram in figure 1.
PRISMA flow diagram: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram details our search and selection process applied during the review. JBI, Joanna Briggs Institute; MAiD, medical assistance in dying.
Data analysis
Data extraction and data analysis
We adopted a thematic synthesis approach to analyse and synthesise data. Thematic synthesis is an adaptation of thematic analysis and provides a set of established methods and techniques that help synthesise qualitative research outcomes, especially when there is heterogeneity in the outcome variables.24 This approach is especially useful in our case since it enables us to examine the meaning, significance and social constructions around the emotional experience of an HCP involved in MAiD. SYD independently coded each line of text according to its meaning and content. Codes were listed as ‘free’ codes, without any hierarchical structure. AB and AS cross-checked the coded data for any discrepancy. Subsequent thematic synthesis was done by SYD, AB and AS in the following two stages:
Stage 1: identifying the similarities between the codes
All relevant qualitative data from the selected studies were extracted manually from the Results, Discussion and Conclusion sections and are represented in online supplemental appendix 3, table 2. The codes were inductively grouped into descriptive themes so that patterns could be identified. The use of line-by-line coding enabled us to undertake translation of concepts from one study to another. Based on the similarities and differences of emerging codes, descriptive themes were generated, and each theme was entered as boxes and codes from each study illustrated in those boxes, so that constant comparison analysis process could be done (see online supplemental appendix 3, table 3).
Supplemental material
Stage 2: development of analytical themes
In this last stage, the descriptive themes were further interpreted using reciprocal translation and constant comparison methods to develop analytical themes. At this stage, the meaning of the patterns of the descriptive themes was analysed against the research question so that a narrative component could be developed.
Once thematic synthesis was completed, each researcher independently evaluated the cumulative evidence from individual studies for methodological limitations, relevance, coherence and adequacy using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) approach (see table 1).25
Descriptive themes and illustrative quotes
All researchers met during regular research review meetings to resolve any discrepancies and achieve consensus over the assessment.
This systematic review was a part of an academic capstone project and was not registered with any international database. The review protocol is available from the research team on request.
In addition to employing the PRISMA checklist for systematic reviews, we used the Enhancing Transparency in Reporting the Synthesis of Qualitative Research checklist to improve the reporting of our meta-synthesis (see online supplemental appendix 4).
Supplemental material
Results
Characteristics of included studies
Thirty-five qualitative research studies were included in the review. The included literature was based in five countries: the USA (7), Netherlands (9), Canada (14), Belgium (1), Switzerland (3), and one study was an international study with participants from the USA and Netherlands. The data included 393 physicians, 169 nurses, 53 social workers in hospice care, 11 allied healthcare professionals (7 personal support workers, 1 pharmacist, 1 genetic technologist and 2 psychologists) and 8 directors of sociomedical institutions and 3 sociocultural animators (applied sociologists who work alongside communities at grass roots to develop and facilitate programmes that support action for local and social changes). A detailed description of the included studies is included in online supplemental appendix 3, table 2.
Thematic synthesis
Stage 1: descriptive themes
Three descriptive emotional themes were derived from the thematic synthesis:
Dimension 1: Strong, internalised and polarised emotions (studies referenced 26–36). These included three subordinate categories/genres:
Positive emotions of ‘reward’, ‘relief’, ‘active openness’ and ‘overwhelming but uplifting’ feelings.
Negative emotions of ‘powerlessness’, ‘guilt’, ‘emotional exhaustion’, ‘vicarious suffering’ and fear of a slippery slope and losing control.
Individual conscience-based emotions of ‘moral shudder’ and moral distress. This emotional dimension was strongly embedded in the cultural and political milieus and the interpersonal communication strategies used by the HCPs.
Dimension 2: Reflective, discourse-based emotions (studies referenced 26 30 36–46)
These included emotions of ‘growing with the patient’s experience’, MAiD as a ‘sense-making process’, ‘de-tabooing the philosophical meaning of death through MAiD’ and various degrees of ‘dynamic conflict’ secondary to a reflective sense of insecurity. These emotions were descriptively laid on a platform of ‘interpretative therapeutic engagement’, where they seemed to aid in the larger philosophical and societal discourse around MAiD.46
Dimension 3: Emotions that resonate with professional values (studies referenced 28 30 34 39 47–61)
These included emotions that resonated with professional values like ‘competency and perfection’, ‘intimate care’, ‘colloque singulier’ (singular language of trust and conscience in context of therapeutic relationship) and various degrees of commitment ranging from ‘contractual’ to ‘sacrificial’.
Table 1 illustrates some of the quotes demonstrating the descriptive emotional themes.
Stage 2: analytical themes
Analytical themes in thematic synthesis typically ‘go beyond’ the findings of the primary studies and generate additional concepts, understandings or hypothesis. At this stage, we used the descriptive themes to answer the review question as to how and why did the HCPs participating in MAiD experience such complex emotions. Each reviewer, initially independent and then as a group, inferred the factors that likely influence the experience of the descriptive themes by questioning how HCPs participating in MAiD represent themselves, or their emotions in the context of their larger healthcare environment. This process was repeated until the new themes were sufficiently abstract to explain all our initial descriptive themes. Altogether, this process resulted in generation of two analytical themes:
Legislative emphasis on terminal illness as a necessary inclusion criterion for MAiD influences the emotional impact. In jurisdictions that legislate MAiD with the central aim to alleviate intolerable suffering in context of terminally ill medical conditions (eg, the USA), the HCPs experience strong polarised emotions that are modulated by their individual cultural/religious background. The extent of emotional impact ranges from positive emotions of reward/relief on one end, to negative (burden, emotional exhaustion) and conscientious-based moral distress on the other. This is in sharp contrast to the emotional impact on HCPs in jurisdictions that legislate MAiD with an emphasis on alleviating intolerable suffering without terminal illness being a necessary requirement (eg, Benelux countries, Switzerland and, more recently, Canada). The HCPs in these jurisdictions experience the emotional impact of MAiD as a ‘sense-making’ process—this allows them to reflect on the emotional dissonance between basic emotions and emotions that conform to legislative rules.
Values associated with the HCPs’ profession and their degree of engagement in the MAiD process are strong influential factors that shape the emotional impact of MAiD. For example, because of their everyday involvement with patients and emphasis on professional values of helping others, compassion and patient advocacy, the emotional impact on nurses involved in MAiD (studies referenced 28 30 34–36 39 41 42 45 53 55 57 60 61) demonstrated strong and polarised positive as well as negative emotions. As one nursing participant noted:
… it’s the hardest nursing. I’ve worked [in the emergency department], I’ve worked medicine floor, this is the hardest nursing there is, having somebody pass away, you actually feel something pulled out of you when that person passes. There’s something missing. … If you take care of somebody for an extended time and they pass away, you just feel, I just feel coldness, or whatever. You just feel drained….36 (p 57)
Appraising the quality of evidence: the Grading of Recommendations Assessment, Development and Evaluation CERQual approach
Evidence from qualitative evidence syntheses is increasingly incorporated into decision-making processes and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) CERQual approach allows the user to make a transparent assessment of how much confidence decision-makers and other users can place in individual review findings from syntheses of qualitative evidence. In order to ascertain the degree of confidence, we graded the evidence in terms of adequacy, relevance, coherence as well as methodological limitations using the GRADE CERQual approach.25 Table 2 illustrates a summary of the findings and the GRADE CERQual profile.
Grading of Recommendations Assessment, Development and Evaluation (GRADE) Confidence in the Evidence from Reviews of Qualitative Research (CERQual) evidence profile
Discussion
Difference in MAiD legislation in Benelux and non-Benelux countries: key features
The substantive and procedural requirements for MAiD across global jurisdictions rest on three main pillars: patients’ right for self-determination expressed through voluntariness of request and a valid informed consent process, foreseeability of natural death due to terminal medical illness and subjective nature of individual suffering.62 63 The key difference between the legislations for MAiD in Benelux countries and countries like the USA is the differential emphasis on eminent or foreseeability of death. The MAiD legislations in Belgium, Netherlands, Switzerland and, more recently, Canada have a more permissive legal framework that allows people to access MAiD as a service to end their intolerable suffering that has no prospect of improvement but is not necessarily terminal.
MAiD legislation and its shaping effect on the emotions of the involved HCP
An important take-home message from this evidence synthesis is how legislations have a shaping effect on emotional responses. The HCPs who practise in the Benelux countries and Switzerland seem to experience more reflective emotions over strong polarising emotions expressed by HCPs who practise in non-Benelux countries like the USA. Canada seems to have a unique transitional position—with the emphasis of the legislation going the Benelux countries’ way, the HCPs’ emotional experiences show a mixture of emotions driven by their professional values as well as the ongoing societal discourse on MAiD. This observation conforms to Michel Foucault’s position on how law acts as an element in the expansion of power(s)64; legislatures along with other platforms of knowledge expression modulate every fibre of human society. Our thematic synthesis points out that the law that limits application of MAiD to terminal illnesses provides for a broader range of emotional expression. Thus, legislation on MAiD across the globe provides the HCP with a locus of administrative control which then decides how the emotional discourse around MAiD is shaped; the question is—how do we want the emotional discourse around MAiD to be shaped?
MAiD legislation, societal values and emotional impact on the involved HCP: a complex relationship
On one end, attitudes of physicians towards MAiD have shown reflective trends to legislative standards; countries like Belgium and Netherlands find much stronger physician support than their USA counterparts.65 On the other end, public support towards MAiD has been reflective of the prevailing societal cultural and religious practices; central and eastern European countries have shown a decline in support with corresponding increase in religiosity as opposed to western European countries.66 67 While an assisted-death legislation with its rules and safeguards provides an obligatory ‘top-down’ framework to embed MAiD within healthcare, it does not necessary reflect the integration of MAiD within the value-based relationships that have traditionally defined an individual’s healthcare.68 Hence, although a MAiD legislation to integrate MAiD into healthcare is a likely reflection of a consensus position of a society, it does challenge the moral environments within which HCPs practise medicine, thereby influencing the emotional impact on HCP. HCPs’ subsequent attempt to align themselves with their own professional values, legislative standards and public perceptions can lead to intense emotional responses, both within their internal, personal and external professional spaces.
Emotional discourse among HCPs involved in MAiD: HCP role and ethics of care
The right to choose when and how to die has always been a contentious issue across various societies.69–71 Public discourse on MAiD is shaped through societal emphasis on individual as well as contextual factors associated with assisted death—these often range from religious beliefs regarding sanctity of human life and personal meaning of death to loss of autonomy associated with illness-related intolerable suffering. With advancing medical technologies, the potential to prolong life has increased significantly,72 73 and the HCPs assume a central position to shape the discourse around assisted death.
In countries where MAiD is legalised but is restricted to terminal illnesses with imminent chance of death, the position of an HCP continues to be one that of a provider of ‘Care’. Here, the moral dimension of ‘Care’ continues to be defined as ‘everything we do to maintain, continue or repair our world so that we can live in it as well as possible’.74 The value of care in healthcare systems has been traditionally associated with attentiveness, responsibility, nurturance, compassion and meeting others’ needs.75 While emotional responses to legal requests of hastening death are affected by policies, professional identity, commitment to patient autonomy, personal values and beliefs, the patient–clinician relationship and will vary on a case-by-case basis,76 this systematic review raises an important question—how does legalising MAiD with emphasis on alleviating intolerable suffering without the context of a terminal illness change the moral dimensions of care?
Conclusion
HCPs involved in MAiD experience a myriad of emotions that include positive/negative emotions; reflective, ‘sense-making’ emotions; and/or professional value-driven emotions. Emphasis on terminal illness only as an essential criterion, MAiD practitioner’s individual professional values and their degree of engagement influence this rich and diverse emotional discourse.
Limitations of the review
This review is limited by its focus of emotional impact on HCPs only and the obvious selection bias in the included studies—those who could and volunteered to express their emotions are represented in the review. The review is also limited with absence of subgroup analysis with respect to HCPs’ age, years of experience and the influence of gender on the results. Restriction to English language studies likely carries a high risk of publication bias.
There are several gaps in our understanding of the emotional impact on HCPs involved in MAiD that would benefit from further research. Intolerable suffering is a common eligibility requirement for assisted death, although HCPs often struggle to understand and assess the nature and normative function of suffering. Is it the very nature of the emotional tone of suffering which is overwhelming or is it more to do with what lies underneath that makes suffering ‘intolerable’? Is there room for humanistic narratives around meaning behind and endurance of one’s suffering? Such questions confront MAiD practitioners and an in-depth exploration of this nebulous concept of intolerable suffering in context of assisted death may help HCPs navigate their emotional experience while providing MAiD.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. Data set 'Codes and themes-qualitative analysis_MAiD_HCP_emotional impact' submitted and published at ZENODO and is available at DOI: 10.5281/zenodo.6778236. No unpublished data.
Ethics statements
Patient consent for publication
Ethics approval
This is a systematic review and meta-synthesis of already published and accessible research data and does not require ethics committee or institutional board approval.
Acknowledgments
The authors acknowledge the valuable contribution of Erica Lenton, Heather Cunningham (library services, Gerstein Library, University of Toronto) and Fiona Inglis (library services, Centre for Addiction and Mental Health, University of Toronto) to consultations and assistance with devising the search strategy.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @saumil1980, @DrSandySimpson
Contributors Study conception and design: SYD, AB, AS. Development of eligibility criteria: SYD, AB, AS. Search strategy developed by Erica Lenton, Heather Cunningham (library services, Gerstein Library, University of Toronto) and Fiona Inglis (library services, Centre for Addiction and Mental Health, University of Toronto) in close consultation with Dr Saumil Dholakia and reviewed by AB and AS. Study selection and data extraction process by Dr Saumil Dholakia and independently reviewed by AB and AS. SYD performed the assessment of risk of bias, which was independently reviewed by AB and AS. Guarantor: SYD. All three authors were involved equally in performing the qualitative meta-synthesis and CERQual assessment. Draft manuscript preparation: SYD with multiple reviews, feedback and edits in form as well as content by AB and AS. All authors reviewed the results and approved the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.