Abstract
Assisted dying (AD) has been a subject of ethical, legal, and emotional debate, particularly
among healthcare professionals. While much research has focused on the experiences of
providers directly involved in AD, less is known about the emotional experiences of non-
provider health professionals (NPHPs) who engage with patients and families in this context.
This study explores the emotional experiences of NPHPs involved in AD in New Zealand,
utilising Lazarus’s Cognitive-Motivational-Relational Theory (CMRT) and Emotional Labour as
theoretical frameworks.
A Heideggerian Interpretive Phenomenological approach was employed, with data collected
through semi-structured interviews with ten NPHPs practicing in New Zealand. The findings
highlight five key themes: (1) finding meaning in the NPHP role, (2) the impact of health
regulations on their experiences, (3) myths and misconceptions surrounding AD, (4) problem-
focused coping mechanisms such as debriefing, education, communication, and peer support and
(5) emotion-focused coping strategies, including emotional regulation and self-care.
This study provides insight into the unique emotional challenges faced by NPHPs and the coping
strategies they employ. The findings have implications for policy, professional support
structures, and training programs to better prepare and support health professionals navigating
AD-related care. Future research should explore broader perspectives and long-term impacts on
NPHPs to inform best practices in healthcare settings. [To be continued: Summary of
Discussion]
Chapter One: Introduction
New Zealand (NZ) legalised assisted dying (AD) with the implementation of the End-of-
Life Choice Act 2019 (the Act) in November 2021. AD encompasses physician-assisted dying
and euthanasia and has become a prominent topic in healthcare, especially as legal regulations
regarding the practice develop worldwide.
Euthanasia refers to…Physician-assisted death refers to… The Act defines AD as the use
of medication to hasten death, which is administered either by medical or nurse professionals or
through self-administration of medication (End of Life Choice Act 2019). The Act allows
patients with terminal illnesses to formally request AD from a health professional if they meet
specific eligibility criteria. These criteria include being 18 years or older, being a NZ citizen or
permanent resident, suffering from a terminal illness expected to end their life within six months,
experiencing an advanced state of irreversible decline in physical capability, enduring unbearable
suffering that cannot be relieved in a tolerable manner, and being competent to make an
informed decision about AD (End of Life Choice Act 2019).
, Beyond AD, various other terms are used across jurisdictions and by researchers to
discuss this type of end-of-life choice, including “voluntary assisted dying” in Australia
(O’Connor et al., 2021), “physician-assisted suicide” in the Netherlands (Gaston et al., 2018),
“medical assistance in dying (MAiD) in Canada” (Fujioka et al., 2018; Ward et al., 2022), aid-in-
dying in some states of the United States (...refences…) and “physician-assisted dying”
(Voorhees et al., 2014). These terms generally refer to the administration of medication with the
intension of hastening death of individual upon their explicit request. In my thesis, I choose to
use “AD”, encompassing physician-assisted dying and euthanasia as it is a relatively neutral term
to describe the administration of death (Tucker et al., 2007 as cited in Gamondi et al., 2019) and
it is term used in the NZ Act.
1.1 AD Roles under the Act
In NZ, AD involves several healthcare professionals, each playing a distinct role to
ensure the process is conducted ethically and remains patient-centered.
1.1.1 Provider and Non-Provider Health Professionals
Medical or nurse practitioners holding a practising certificate may register with the
Support and Consultation for End of Life in New Zealand (SCENZ) group to perform AD
(MOH, 2024). For my thesis, these practitioners are categorised as provider health professionals
(PHPs); meanwhile, those who do not to perform AD fall under the non-provider health
professionals (NPHPs) category. NPHPs may choose to provide care to patients undergoing AD
but have different reasons for not performing AD. For instance, lack of practicing qualifications
(e.g., nurses, social workers, spiritual carers) (Brooks, 2019), inadequate skills or experiences,
conscientious objection ar(CO) to AD, or working in settings with an institutional objection (IO)
to AD (MOH, 2024; Snelling et al., 2023). CO occurs when health professionals refuse to
provide AD based on moral or conscientious grounds. Similarly, IO refers to organisations
declining to provide or facilitate AD services, regardless of their health professionals’
willingness (Snelling et al., 2023). Regardless of personal, professional, or institutional stances
on AD, all health professionals must report to the SCENZ group, explain to patients if the
,request was made, and refer them to another AD expect (Health New Zealand Te Whatu Ora,
2024).
Snelling and associates (2023) identified four distinct group of views held by healthcare
professionals regarding AD. Those who abstain from AD procedures and reject them for moral
reasons are called ‘conscientious objectors’. Those who initially resisted AD but now assist with
certain parts of AD care without directly participating in the process are called ‘reluctant AD
facilitators’. ‘AD participants’ refer to those who directly involved in AD provision and support
its provision. Finally, ‘non-participator allies’ who are some supporters but not directly involved
with AD due to reasons such as institutional, legal or other limitations (Snelling et al., 2023).
1.1.2 Roles in the AD Process
(add do no harm)
An attending medical practitioner (AMP) is a health practitioner who is primarily
responsible for providing end-to-end care throughout the AD process, including the eligibility
criteria assessment and administration of the lethal medication (Ministry of Health Manatū
Hauora [MOH], 2024). AMP can be a person’s regular medical practitioner (physician/doctor) or
someone from the SCENZ Group list. An attending nurse practitioner (ANP) is a nurse
practitioner registered with the Council Nursing of NZ with current practicing certificate who
may participate in various forms, such as involving in AD decision-making or administering AD
medication under the AMP’s instruction (MOH, 2024). An independent medical practitioner
(IMP) is a medical practitioner who provides the second eligibility assessment, independent of
the AMP, in the AD process and must also be listed with the SCENZ group (MOH, 2024).
1.2 The AD Process
The AD process follows a structured protocol to ensure that patients’ rights, well-being,
and informed decision-making are prioritised. The process begins when patients or their families
initiate a conversation about AD with a health professional (MOH, 2024). Health professionals
are not permitted to suggest AD themselves; however, they are legally obliged to provide
information and guidance upon request. Patients may seek clarification on AD procedures and
reasons for considering AD. They can access resources online or consult with any health
, professional within their network. Health professionals may also suggest relevant resources for
patients to explore. Once a patient decides to pursue AD, they can make a formal request to their
AMP, who discusses AD and other end-of-life care options with them, as well as consult with the
healthcare team and whānau (with the patient’s consent). The patient then signs a form with an
eligibility assessment.
The AMP will review the patient’s medical notes and meet with them in person, allowing
whānau or a support person to be presented. At times, the AMP may speak with the patient
alone. Even though AD is accessible to patients, safeguards ensure careful evaluation of every
patient’s request. The AMP must clarify the patient’s reasons for seeking AD, ensuring it is well-
considered. If the AMP finds that the patient is meeting all the eligibility requirements and
deems them eligible, an IMP will conduct a second independent assessment. Both medical
practitioners must agree that the patient is eligible for the process to move forward. Additionally,
if concerns arise about the patient’s competency to make an informed decision, a psychiatrist
may be involved in evaluating their mental health. no-one else can make the decision about
assisted dying on your behalf or pressure you into this option. If you are being pressured into
choosing assisted dying, the process will stop. You’ll be given support and advice on other care
options. Add here about any detected coercion will stop the process. Eligible patients would plan
for assisted death with the AMP or ANP who will help the patient and their whānau make
decisions about timing, location, type of medications (intravenous or oral), and any social,
cultural, or spiritual support they may need . A comprehensive care plan will be developed to
guide this process.
If the patient is deemed ineligible, the AMP will inform them and their whānau, explain
the ineligibility reasons and ensure access to appropriate care and support. On the chosen date,
the AMP and ANP will require an informed consent confirming their continued willingness to
proceed with the patient. If the patient is deemed still competent and willing to proceed, the
medication will be administered, and the health professional will stay with the patient and their
whānau until after death. Following the death, a clinical advisor from the MOH will contact the
whānau at an agreed time to offer support or advice if desired. Until here, the therapeutic
relationship ended. Before patients left, the health professionals still providing care throughout
the process. The care for whānau may continue provided by health professionals depending on
whānau’s need. This entire process forms the basis for discussions on the practical, ethical, and
Assisted dying (AD) has been a subject of ethical, legal, and emotional debate, particularly
among healthcare professionals. While much research has focused on the experiences of
providers directly involved in AD, less is known about the emotional experiences of non-
provider health professionals (NPHPs) who engage with patients and families in this context.
This study explores the emotional experiences of NPHPs involved in AD in New Zealand,
utilising Lazarus’s Cognitive-Motivational-Relational Theory (CMRT) and Emotional Labour as
theoretical frameworks.
A Heideggerian Interpretive Phenomenological approach was employed, with data collected
through semi-structured interviews with ten NPHPs practicing in New Zealand. The findings
highlight five key themes: (1) finding meaning in the NPHP role, (2) the impact of health
regulations on their experiences, (3) myths and misconceptions surrounding AD, (4) problem-
focused coping mechanisms such as debriefing, education, communication, and peer support and
(5) emotion-focused coping strategies, including emotional regulation and self-care.
This study provides insight into the unique emotional challenges faced by NPHPs and the coping
strategies they employ. The findings have implications for policy, professional support
structures, and training programs to better prepare and support health professionals navigating
AD-related care. Future research should explore broader perspectives and long-term impacts on
NPHPs to inform best practices in healthcare settings. [To be continued: Summary of
Discussion]
Chapter One: Introduction
New Zealand (NZ) legalised assisted dying (AD) with the implementation of the End-of-
Life Choice Act 2019 (the Act) in November 2021. AD encompasses physician-assisted dying
and euthanasia and has become a prominent topic in healthcare, especially as legal regulations
regarding the practice develop worldwide.
Euthanasia refers to…Physician-assisted death refers to… The Act defines AD as the use
of medication to hasten death, which is administered either by medical or nurse professionals or
through self-administration of medication (End of Life Choice Act 2019). The Act allows
patients with terminal illnesses to formally request AD from a health professional if they meet
specific eligibility criteria. These criteria include being 18 years or older, being a NZ citizen or
permanent resident, suffering from a terminal illness expected to end their life within six months,
experiencing an advanced state of irreversible decline in physical capability, enduring unbearable
suffering that cannot be relieved in a tolerable manner, and being competent to make an
informed decision about AD (End of Life Choice Act 2019).
, Beyond AD, various other terms are used across jurisdictions and by researchers to
discuss this type of end-of-life choice, including “voluntary assisted dying” in Australia
(O’Connor et al., 2021), “physician-assisted suicide” in the Netherlands (Gaston et al., 2018),
“medical assistance in dying (MAiD) in Canada” (Fujioka et al., 2018; Ward et al., 2022), aid-in-
dying in some states of the United States (...refences…) and “physician-assisted dying”
(Voorhees et al., 2014). These terms generally refer to the administration of medication with the
intension of hastening death of individual upon their explicit request. In my thesis, I choose to
use “AD”, encompassing physician-assisted dying and euthanasia as it is a relatively neutral term
to describe the administration of death (Tucker et al., 2007 as cited in Gamondi et al., 2019) and
it is term used in the NZ Act.
1.1 AD Roles under the Act
In NZ, AD involves several healthcare professionals, each playing a distinct role to
ensure the process is conducted ethically and remains patient-centered.
1.1.1 Provider and Non-Provider Health Professionals
Medical or nurse practitioners holding a practising certificate may register with the
Support and Consultation for End of Life in New Zealand (SCENZ) group to perform AD
(MOH, 2024). For my thesis, these practitioners are categorised as provider health professionals
(PHPs); meanwhile, those who do not to perform AD fall under the non-provider health
professionals (NPHPs) category. NPHPs may choose to provide care to patients undergoing AD
but have different reasons for not performing AD. For instance, lack of practicing qualifications
(e.g., nurses, social workers, spiritual carers) (Brooks, 2019), inadequate skills or experiences,
conscientious objection ar(CO) to AD, or working in settings with an institutional objection (IO)
to AD (MOH, 2024; Snelling et al., 2023). CO occurs when health professionals refuse to
provide AD based on moral or conscientious grounds. Similarly, IO refers to organisations
declining to provide or facilitate AD services, regardless of their health professionals’
willingness (Snelling et al., 2023). Regardless of personal, professional, or institutional stances
on AD, all health professionals must report to the SCENZ group, explain to patients if the
,request was made, and refer them to another AD expect (Health New Zealand Te Whatu Ora,
2024).
Snelling and associates (2023) identified four distinct group of views held by healthcare
professionals regarding AD. Those who abstain from AD procedures and reject them for moral
reasons are called ‘conscientious objectors’. Those who initially resisted AD but now assist with
certain parts of AD care without directly participating in the process are called ‘reluctant AD
facilitators’. ‘AD participants’ refer to those who directly involved in AD provision and support
its provision. Finally, ‘non-participator allies’ who are some supporters but not directly involved
with AD due to reasons such as institutional, legal or other limitations (Snelling et al., 2023).
1.1.2 Roles in the AD Process
(add do no harm)
An attending medical practitioner (AMP) is a health practitioner who is primarily
responsible for providing end-to-end care throughout the AD process, including the eligibility
criteria assessment and administration of the lethal medication (Ministry of Health Manatū
Hauora [MOH], 2024). AMP can be a person’s regular medical practitioner (physician/doctor) or
someone from the SCENZ Group list. An attending nurse practitioner (ANP) is a nurse
practitioner registered with the Council Nursing of NZ with current practicing certificate who
may participate in various forms, such as involving in AD decision-making or administering AD
medication under the AMP’s instruction (MOH, 2024). An independent medical practitioner
(IMP) is a medical practitioner who provides the second eligibility assessment, independent of
the AMP, in the AD process and must also be listed with the SCENZ group (MOH, 2024).
1.2 The AD Process
The AD process follows a structured protocol to ensure that patients’ rights, well-being,
and informed decision-making are prioritised. The process begins when patients or their families
initiate a conversation about AD with a health professional (MOH, 2024). Health professionals
are not permitted to suggest AD themselves; however, they are legally obliged to provide
information and guidance upon request. Patients may seek clarification on AD procedures and
reasons for considering AD. They can access resources online or consult with any health
, professional within their network. Health professionals may also suggest relevant resources for
patients to explore. Once a patient decides to pursue AD, they can make a formal request to their
AMP, who discusses AD and other end-of-life care options with them, as well as consult with the
healthcare team and whānau (with the patient’s consent). The patient then signs a form with an
eligibility assessment.
The AMP will review the patient’s medical notes and meet with them in person, allowing
whānau or a support person to be presented. At times, the AMP may speak with the patient
alone. Even though AD is accessible to patients, safeguards ensure careful evaluation of every
patient’s request. The AMP must clarify the patient’s reasons for seeking AD, ensuring it is well-
considered. If the AMP finds that the patient is meeting all the eligibility requirements and
deems them eligible, an IMP will conduct a second independent assessment. Both medical
practitioners must agree that the patient is eligible for the process to move forward. Additionally,
if concerns arise about the patient’s competency to make an informed decision, a psychiatrist
may be involved in evaluating their mental health. no-one else can make the decision about
assisted dying on your behalf or pressure you into this option. If you are being pressured into
choosing assisted dying, the process will stop. You’ll be given support and advice on other care
options. Add here about any detected coercion will stop the process. Eligible patients would plan
for assisted death with the AMP or ANP who will help the patient and their whānau make
decisions about timing, location, type of medications (intravenous or oral), and any social,
cultural, or spiritual support they may need . A comprehensive care plan will be developed to
guide this process.
If the patient is deemed ineligible, the AMP will inform them and their whānau, explain
the ineligibility reasons and ensure access to appropriate care and support. On the chosen date,
the AMP and ANP will require an informed consent confirming their continued willingness to
proceed with the patient. If the patient is deemed still competent and willing to proceed, the
medication will be administered, and the health professional will stay with the patient and their
whānau until after death. Following the death, a clinical advisor from the MOH will contact the
whānau at an agreed time to offer support or advice if desired. Until here, the therapeutic
relationship ended. Before patients left, the health professionals still providing care throughout
the process. The care for whānau may continue provided by health professionals depending on
whānau’s need. This entire process forms the basis for discussions on the practical, ethical, and
