DIAGNOSED with breast cancer at age 38, “Jolene,” now 44, is admitted to the hospital for complications secondary to chemotherapy. Following a bilateral radical mastectomy, she'd been cancer-free for 5 years. However, 3 weeks ago Jolene sat silently, heart pounding, palms sweating, as the oncologist explained that the cancer had metastasized to her lymph nodes, lungs, and spine. Jolene swallowed the lump in her throat as the oncologist discussed her grave prognosis—she has only months to live.
The nurses listen intently as Jolene sobs and explains her fear of losing her autonomy and becoming a burden on her husband: “He didn't bargain for this.” She alternates between laughter and tears as she reminisces about her marriage and the love she shares with her husband. Jolene smiles as she tells the nurses about the upcoming birth of their first grandchild.
Nonetheless, Jolene is in tremendous pain related to bone metastasis and often struggles to breathe because of tumors in her lungs. Today, she tells her nurse that her physical pain and emotional anguish are too much to bear, and that she'd rather die now than endure such pain and be a burden to her family.
In the state of Oregon, Jolene's remarks can be considered an opening for dialog about physician-assisted suicide (PAS) under Oregon's Death with Dignity Act (DWDA). Washington and Vermont have also passed legislation legalizing PAS performed according to specific guidelines, and PAS is considered legal in Montana based on a state Supreme Court ruling. In several other states, legislation to legalize PAS is pending. This article presents one view of the nurse's role in PAS in light of Oregon's DWDA.
Passed in 1997, Oregon's DWDA allows physicians to prescribe lethal doses of medications to hasten the death of mentally competent, terminally ill adults who make this request.1 Patients must be Oregon residents and meet various other eligibility requirements (see Oregon's Death with Dignity Act). Although physicians may legally write a prescription for a lethal dose of medication for patients who request it and who meet the eligibility requirements, patients must administer the medication themselves.
PAS must not be confused with euthanasia, which involves someone other than the patient (such as a family member or nurse) administering a lethal dose of medication with the intention of ending the patient's life.1,2 Requiring patients to self-administer the medication supports the legislative intent that patients remain in control of the decision to commit suicide.
However, even though strict criteria have been developed to determine eligibility, PAS presents complex ethical and practical challenges and risks. For example, who ensures that the patient is, in fact, the one who administers the drug? What if a patient's diagnosis or prognosis is wrong?
Americans are living longer and for most nurses, caring for patients at the end of life is inevitable. With the growing acceptance of PAS and an increasing number of states placing PAS on legislative ballots, nurses must be prepared to educate patients who request more information.
Initiating a discussion regarding PAS isn't advisable due to the potential for an accusation of coercion, but nurses can respond if a patient requests information.3 However, they must first examine their personal beliefs regarding PAS, acknowledging that their values and beliefs may differ from those of their patients. Although nurses don't necessarily have a duty to cooperate with healthcare choices that are contrary to their own deeply held values, they do have a responsibility to assess whether patients are aware of options, risks, and alternatives so patients can make informed decisions regarding their care.4
Sorting out personal values
When addressing PAS, nurses must determine whether they believe assisting a suffering human being to commit suicide is compassionate and merciful or an “overt act of killing.”5
Some nurses may view PAS as compassionate release from senseless suffering. However, in a study by Gielen, Van den Branden, and Broeckaert, several nurses argue that “... the hour of death can be determined only by God and that people should not interfere by actively hastening death.”2 Either way, every nurse must ascertain his or her personal feelings and beliefs regarding PAS. This awareness helps the nurse offer objective information and enhances preparedness when difficult subjects arise, including patient inquiries regarding diagnosis and prognosis.
Consider the risks
Terminal illness makes patients and families susceptible to physical, emotional, and spiritual distress. Older patients may worry about becoming a burden to their family at end of life. Patients and families alike can become overwhelmed and make irrational decisions.
Besides considerations of irrationality, guilt, and coercion, a request for PAS might also be precipitated secondary to the effects of depression. Although freedom from depression is a legal prerequisite for PAS, terminal illness and depression often go hand-in-hand; even astute clinicians can miss this diagnosis. Referrals must be made as needed to evaluate patients for depression, pain, and other stressors that may be influencing their request for PAS.
What about other options?
Patients and families should also consider alternatives to PAS. Empowering patients through education is key. Helping them create a living will and a durable power of attorney for healthcare can not only increase a patient's autonomy and sense of control, but also improve quality of life.
Many patients at the end of life are afraid of suffering excruciating pain. Jolene expressed this very fear to her nurse. Nonetheless, the nurse can assure Jolene that many effective pain control options are available that don't include intentionally ending her life.
A less ethically charged alternative to PAS for terminally ill patients with severe, poorly controlled pain is palliative sedation. This therapy involves providing medications for patients at the end of life to reduce the level of consciousness and decrease pain and suffering while allowing natural death to occur. Other options patients can consider include refusing nutrition and hydration and refusing life-sustaining treatments, such as antibiotics to treat pneumonia. Whatever the decision, patients should be reassured that they won't be abandoned and that they'll continue to receive comfort measures and palliative care.
Whether Jolene's death is natural or assisted, she needs a sensitive, educated, compassionate, and nonjudgmental nurse to intervene and serve her through sound education on options and quality care to enhance the life she has left to live. Whatever choices a patient makes, nurses must remember that PAS is a complicated ethical issue. Nurses must know where they stand, stand up, and remain standing.
DWDA by the numbers6
In 2012 (as of January 14, 2013), 115 prescriptions for PAS were written in Oregon under the DWDA, according to Oregon Public Health Division statistics.
- 66 patients who received prescriptions in 2012 ingested and died from the medication that year. In addition, 11 patients who'd received prescriptions the previous year ingested and died from the medication, for a total of 77 DWDA deaths in 2012.
- in 2012, one patient ingested the medication, regained consciousness about 2 days later, and died of the underlying illness about 6 days after ingestion. (This was not counted as a DWDA death.)
- 23 patients with prescriptions written in 2012 didn't ingest the medication and died of other causes.
- the ingestion status for the remaining 25 patients was unknown at the time of the 2012 report.
The median age of the 77 patients counted as DWDA deaths in 2012 was 69. Most (97%) died at home and were enrolled in hospice care. About 75% had a cancer diagnosis. Prescribing physicians were present at the time of death for seven patients.