Assisted Suicide: What Role for Nurses?

Carrie Farella, RN, MA *

[The hospice agency for which Jill Allene, RN, works has cared for four patients who chose PAS under Oregon's Death with Dignity Act.]

On a cold Friday in January, Oregon nurse Jill Allene, RN, visited her elderly hospice patient, Gus,* as she had many times before. Her eyes moved over him slowly, assessing him closely. They joked about baseball, about family, about life. When she finished, she gathered her belongings, extending her hand to him as they said their goodbyes. The next day, surrounded by those he loved, Gus swallowed a lethal mixture of medications that had been prescribed by his physician and fell into a deep sleep. He died soon after, wearing his favorite baseball cap.

Gus didn't win his battle with disease, but he did win a war - a war of control. He wanted simply to die on his terms, under circumstances he chose. Like others in Oregon who have opted to use that state's legalized physician-assisted suicide (PAS), it wasn't unrelenting surges of pain or incapacitating waves of nausea that encouraged Gus to call it quits; it was an unquenchable thirst for autonomy. Pulmonary disease didn't kill Gus - Gus killed himself.

"This man was not the picture of suffering as I know it," says Allene, who, though she did not witness the death, was a party to it all the same. Since Oregon broke new ground with its 1997 Death with Dignity Act - becoming the only state in the nation to legalize PAS - nurses there are assuming roles they may not have anticipated, sometimes uncomfortably so. Ironically, Oregon's nurses are finding themselves, not physicians, on the front line of PAS. It's a place where physicians might actually prefer them and one to which some nurses have already gone.

Better You Than Me

"Initially, when the law was designed, the assumption was that physicians would be the first ones to explore PAS with patients," says Pam Matthews, RN, BSN, administrator for Evergreen Hospice, Albany, OR, "but in reality, nurses are usually the ones in the line of fire. Patients often feel nurses understand their wishes for good quality of life and good quality of death, too."

Much of nurses' roles lies behind the scenes long before the drama of PAS unfolds. Home care and hospice nurses actively help patients understand their rights, acting as advocates for those who are considering PAS.

"Patients often ask about PAS," says Allene. "They want to learn more and feel comfortable asking their nurses about it."

Allene's agency has cared for four patients who have opted to use PAS. Gus was Allene's first such patient. "Our entire hospice team was involved in this patient's case - all trying to pick his brain, making sure he had no unmet needs we could fill or pain that was going untreated," she says. "We wanted to be sure that he saw all possible options before using PAS."

It's that kind of strong patient advocacy that has physicians - in general opposed to PAS - speculating whether nurses are better-suited to a more direct role in the process. Some physicians have stated publicly that they may not be the best members of the healthcare team to lead assisted dying, confessing that they are not always the most properly prepared for the task. A recent article in the Annals of Internal Medicine (AIM) stated PAS violates physicians' professional integrity and suggests that other disciplines, such as nursing, may be more capable of leading assisted-dying efforts.1

"To say that physicians alone are the only ones capable of assisting a patient's suicide is not that easy," says Jason Karlawish, MD, of the University of Pennsylvania Center for Bioethics' Assisted Suicide Consensus Panel, and coauthor of the AIM article. "The problem is that it [PAS] requires skills that the average physician does not have - and shouldn't have. We [physicians] should be able to treat those who are dying, relieving their pain and symptoms, but not helping them kill themselves."

Although nurse practitioners (NPs) can write prescriptions for schedule II medications in Oregon, nurses like Allene are hoping the current law will evolve to include expanded PAS rights for NPs. Or, suggests Karlawish, "maybe a new profession should be created to perform PAS - a nurse with additional certification, or a physician with additional certification. This is too significant an act to not know what you're doing."

Been There

Knowing what you're doing and doing it are completely different matters, particularly when it comes to assisted dying. PAS divides many in nursing. "Many RNs believe that to intentionally assist another in dying is to participate in killing," says Judith Kennedy Schwarz, RN, MS, doctoral candidate, division of nursing, New York University, and a consultant in nursing ethics and expert in the subject of assisted dying. "They see it as disrespect for life and something that''s prohibited by law, our nursing code of ethics, and our practice guidelines." Other nurses see the issue quite differently. Assisted dying, they say, goes on every day in subtle, unspoken ways.

"I think a lot of nurses out there have given someone a little too much morphine at one time to ease a patient's pain," says B, a hospice nurse from Seattle, who asked for anonymity, "and they do so knowing full well the consequences of their actions."

The American Nurses Association believes nurses' participation in assisted suicide violates the ethical standards of its Code for Nurses. The association draws a distinction between nurses' participation in assisted suicide and euthanasia and their provision of medications that have the unintentional effect of ending a patient's life. "The nurse may provide interventions to relieve symptoms in the dying client," the code states, "even when the interventions entail substantial risks of hastening death."2

But a recent survey of oncology RNs supports the theory that some nurses do, in fact, help the dying process along. The survey found that nurses (4%) were more likely than physicians (1%) to carry out patient-requested euthanasia - a deliberate and intentional act that causes the death at a patient's request, such as administering a lethal injection, as opposed to assisted suicide, defined as the provision of a means to end life, such as a prescription for a lethal amount of a drug or the drug itself.

Of the 441 nurses surveyed, 30% reported receiving requests for lethal drugs in the previous year, and 25% of nurses reported requests for lethal injections. One percent of the RNs admitted helping a patient commit suicide, 4.5% reported performing patient-requested euthanasia, and 2% admitted injecting a lethal drug into a patient more than once in the previous year.3 Ironically, nurses who had participated in assisted dying frequently consulted physicians but rarely approached another nurse for support.4

"It's hard to find anyone who will talk about helping patients die, whether it be illegal euthanasia or legal PAS,"" says an Oregon nurse. "It''s still quite taboo for anyone to talk about PAS, and nurses are among them, despite its legality." It's also difficult for patients to find a physician who will talk to them about PAS or consider writing them a prescription for the lethal medication. Some patients visit several physicians before they find one who will help them carry out PAS. Currently, only one in 10 patients who request PAS are given a prescription for it.

For Some, Easier Said Than Done

But even when nurses support PAS, they might not understand how they feel about assisted dying until they're faced with it.

"Although I support the patient's right to die, I'm always saddened by the fact that some people don't choose life," says Lynda Moses, RN, BSN, a nurse at a Portland-area hospice who felt pulled in opposite directions when her patient chose PAS.

"I had felt OK with the law until it actually became a reality for one of my patients," she says. "When the patient's physician asked me if I'd be willing to be present when the patient took his own life, I was surprised to find myself in a quandary. I could see myself being there and crying out, 'Stop!'"

Moses was relieved that her patient died of natural causes shortly before he was to take his own life. "It made me realize just how uncomfortable I was about PAS, even though I still believe it should be a patient's right. I have no problem caring for patients after they've taken lethal prescriptions - I just don't want to be there when they do."

She isn't alone. Nurses across Oregon report confusion about their feelings toward PAS, although many hospices were preparing for the law's fallout long before it hit the books.

"Before PAS became law, it was publicly debated, and we performed surveys of our hospice teams' feelings on the issue," Matthews says. "We found that most nurses felt strongly that patients should have the choice of PAS, although most said they would not participate in the event."

Legal - and Lethal

Drawing national attention in November 1994 when it was first passed, Oregon's Death with Dignity Act was held in limbo by a court injunction for nearly two years. The law was finalized in October 1997.

The act legalizes PAS, but clearly prohibits euthanasia. Ironically, however, the only legal "assistance" physicians may provide for terminally ill patients a prescription for a lethal dose of medication. No recipe or magic potion exists - physicians work with pharmacists to tailor-make a mixture for each patient. Patients take the oral medication themselves and must meet other stringent criteria before a prescription is written.

Aside from being a legal resident of Oregon, anyone interested in PAS must be at least 18 years old and capable of communicating his or her healthcare decisions. Patients must also be diagnosed with a terminal illness and have fewer than six months to live. The request for PAS must be voluntary. One written and two verbal requests must be made, and the verbal requests for PAS must be separated by at least 15 days. A consultant physician must confirm a patient's terminal diagnosis, and if either the consultant or the patient's physician suspects the patient may be depressed, a thorough psychiatric examination must be performed. The patient must also be made aware of comfort measures that are available through hospice services.

Not everyone in the state has the right to PAS. According to a 1998 Oregon Health Division report, federal law prohibits participation in PAS by patients or physicians within federal healthcare systems, such as Veterans Administration hospitals. Some private healthcare systems, including one Catholic medical system in Oregon, have placed similar restrictions on patients and staff within their facilities.5

Between 1998 and 1999, more than 43 patients have taken advantage of their right to commit legalized suicide in Oregon. The average patient was 71 years old. 6

Death Be Not Chosen

Before PAS became law, opponents theorized that Oregon would become a breeding ground for Kevorkian-like physicians - physicians in the death business. They also feared people would flock to the state because of the availability of PAS. So far, neither fear has become reality.

"We''re not seeing people come to Oregon to die. And as far as 'death doctors,' we aren't seeing that, either," says Matthews.

PAS opponents were also afraid people would confuse hospice care with PAS and conclude that hospices hasten death. Thankfully, that doesn't seem to be the case, either.

"One consequence of PAS is that we have very informed citizens," says Virginia Tilden, RN, DNSc, FAAN, associate dean for research at Oregon's Health Science University, Portland. "Oregonians understand that they have the right to good pain management, symptom control, and a better quality of dying. It's a unique right of control, but a legal one all the same."

Legal - for now. The Pain Relief Promotion Act, a federal proposal that would have the effect of stripping Oregonians of their right to PAS, is clipping along through Congress (see "Proposed Legislation Would Mean Death for Assisted Suicide"). If passed, the legislation would prevent the Guses of Oregon - or of any other state - from exercising autonomy in their lives - and deaths.

This would be welcome news for some nurses, but for others, bad tidings. "It's gut-wrenching to see a terminally ill patient suffer," says B. "What's happening in Oregon is a good thing - for patients who want a choice."

*Name has been changed.

References

1. Faber-Langendoen K, Karlawish J. Should assisted suicide be only physician assisted? Ann Intern Med. 132:483.

2. American Nurses Association. Position statement on assisted suicide. Accessed May 2, 2000.

3. Kennedy Schwarz J. Assisted dying and nursing practice. Image J Nurs Sch. 1999; 3(4):368.

4. Matzo LaPorte M, Emmanuel EJ. Oncology nurses' practices of assisted suicide and patient-requested euthanasia. Oncol Nurs Forum. 24:1731.

5. Oregon's Death with Dignity Act: The first year's experience. Accessed April 5, 2000.

6. Oregon Health Division, 1998 Annual Report on Oregon's Death with Dignity Act. Accessed April 5, 2000.