Nursing’s Role in Assisted Suicide

February 24th, 2012

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"Death is not extinguishing the light; it is putting out the lamp because the dawn has come."

                                                                              Rabindranath Tagore

                                                                                                     May 7, 1861-August 7, 1941

By , BSN, RN

Laurel Lewis of the Death and Dying Dinner Parties brought this quote to my attention. Death is a universal topic. Now, in the Netherlands, nurses and doctors traveling in mobile units will be legally helping terminally ill patients end their own lives at home. The Netherlands legalized euthanasia in 2002.

Even with the passage of the law, many doctors are reluctant to take part in a patient’s willingness to end their own life. In response, a Dutch association will next month launch six mobile units of doctors and nurses to help terminally ill patients carry out voluntary euthanasia.

Right to Die-NL, know as NVVE, was established in 1973 after a doctor was found guilty of voluntary euthanasia and received a one-week suspended sentence. The society today has 131, 000 members and some 150 volunteers in the Netherlands.

“Many doctors and nurses who work for us are 'semi-volunteers,' meaning they have other, main jobs,” said NVVE spokeswoman Walburg de Jong. “It is their conviction (in favor of euthanasia) that makes them help the NVVE.”

Each of the six teams will be comprised of a doctor and one or two nurses, available to help patients pass away in a “dignified and painless” manner. The teams will make sure the patients meet the legal criteria for allowing them to die voluntarily.

The procedure can only be performed if the patient has an incurable disease, intolerable pain, and no hope of improvement. Patients must also state clearly that they wish to die. “Usually, patients want to die at home, but we also have a clinic to help them when the time comes,” de Jong said.

In the United States

Euthanasia is illegal in the United States but, assisted suicide is legal in three states: Washington, Oregon, and Montana. The difference between the two is who administers the lethal dose of medication. When a doctor or nurse or other third party gives the final dose, it is “euthanasia.” Assisted suicide, also know as physician aid-in-dying (PAD) means the patient will self-administer a medication, hence, also deciding where and when to do so. Controversy surrounds both topics at every turn.

Just two weeks ago the Georgia Supreme Court rejected a law intended to discourage assisted suicide. The court however, did not actually rule in favor of assisted suicide being legal, instead they said that a law aimed at controlling assisted suicide was unconstitutional. The Georgia law, which made the act of promoting assisted suicide an element of the crime, was deemed a violation of the freedom of speech.

Where Do Nurses Fit In?

In ethical debates about euthanasia and assisted suicide the focus is usually on the involvement of doctors; nurses are seldom given much thought at all. Yet, it is a topic that greatly affects nurses. Nurses are the ones at the bedside of the dying—24 hours a day, every day. Nurses are there for the patients, assessing and managing pain, and other symptoms. They are there for the patients and their families addressing their spiritual needs, their anxieties, and their questions.

Nurses often find themselves in a quandary. While many of the professional nursing and hospice associations have come out publicly against the legalization of and participation in euthanasia or assisted suicide, this doesn’t usually help the nurse who is standing in front of the patient asking to die with an appropriate response.

Surveys over the years show that somewhere between 17-40 percent of nurses working in critical care and hospice have received requests from patients or family members to perform euthanasia or assist in suicide. One of these surveys showed that 16 percent of nurses responding have participated in these practices. And, while there is debate over the actual validity of the number and the actual acts (the administration of opiates to dying patients, a practice that generally is considered different from assisted death and morally acceptable) a significant number of nurses have said they have provided or prescribed drugs to a patient knowing the patient intended to use them to end their own lives.

These studies have highlighted a number of important issues surrounding nurses and euthanasia, assisted suicide and relief of suffering:

  1. Nurses are witness to tremendous suffering. – Nurses need to be supported and educated in ways to lessen suffering. Also, RNs need to identify their own responses to suffering and distress or they won’t be able to identify which patient’s suffering is being addressed through assistance in dying.
  2. There is confusion about the differences between euthanasia, assisted suicide and relief of suffering. – If nurses are unable to discriminate between these actions they may unwittingly place themselves at risk for unexpected emotional and legal consequences.
  3. Nurses need guidance in discerning the moral and legal distinctions among various nursing actions at the end of life. – One study showed 25% of RNs responding to the survey included written comments, many of which reflected the uncertainty and distress that nurses experience in the "gray and persistently uncomfortable" area of relieving pain at the end of life.
  4. Nurses need guidance in making ethical decisions that honor individual differences. – Nurses need to understand their rights as well as the ethical and legal complications of their actions. No matter what, some nurses will participate in assisted death, even if they are not in a state that calls it legal. Other nurses will refuse to assist even if they work in a state that sanctions end of life actions.

This is not a topic that will find final answers anytime soon; not here in the United States, not in other countries, not even in the Netherlands. The NVVE says on its website that about 2 700 people choose assisted suicide each year in the Netherlands. But, even with the passage of the laws protecting doctors and nurses from prosecution many are still afraid of performing euthanasia, de Jong says.

Despite the NVVE's insistence on the legality of its activities, the mobile medical teams are likely to spark controversy at home and abroad.

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