End of life is an inevitable part of human existence. There are several options patients have at end of life, including hospice, palliative care and physician-assisted death, to name a few. Physician-assisted death (PAD) is the practice by which a physician provides a prescription for a potentially lethal medication to a suffering, terminally ill patient, at the patient’s request. The medication allows the patient to choose if, and when to take the potentially lethal dose. PAD is also called physician-assisted suicide, physician aid-in-dying, and medical aid-in-dying. A patient that requests PAD must meet certain criteria to participate. The criteria for each state in the United States that has legalized the practice may differ slightly in eligibility. Physician-assisted death has become an increasingly discussed topic in the United States, with several ethical and legal dilemmas arising.
Assisted death is available in various forms internationally, including Colombia, the Netherlands, Belgium, Luxembourg, and most recently Canada (Stokes, 2017, p. 151). Although the majority of the states currently prohibits this practice, PAD is currently legal in six states including Oregon, Washington, Hawai’i, California, Vermont, Colorado, and also Washington D.C. (Death with Dignity, 2018, table 1). The United States supreme court stated it was not a constitutional right, remaining neutral in the matter. They returned it to an individual state level decision (Olin, 2012, para. 8). In 1997 Oregon was the first state to pass the Death with Dignity Act (DWDA), legalizing PAD. According to Stokes (2017):
Each state where PAD is legal by statute, has similar laws on participation and all states mandate that a patient meet the following criteria: (1) the patient must have a terminal illness diagnosed by 2 physicians, (2) the patient must be 18 years of age, (3) the patient must be a state resident, (4) the patient must be mentally competent, and (5) the patient must provide informed consent (p. 151).
All states allow patients to change their mind at any point in the process. Only after meeting all criteria, individuals in Oregon receive a life ending prescription. There are 23 other states that are considering legalizing PAD this year. Montana is the only state that has ruled Death with Dignity legal by court decision (Death with Dignity, 2018, table 1).
According to Johnson, Cramer, Conroy, & Gardner (2013), a patient is considered to be competent to make an informed decision:
based on appreciation of the relevant facts and after being fully informed by the attending physician of: a) his or her medical diagnosis; b) his or her prognosis; c) the potential risks associated with taking the medication to be prescribed; d) the probable result of taking the medication to be prescribed; and e) the feasible alternatives, including, but not limited to, comfort care, hospice care, and pain control (ORS 127.800 § 1.01.7) (p. 583).
The law states that a mental health professional does not need to be involved unless “the attending or consulting physician believes the patient is ‘suffering from a psychiatric or psychological disorder or depression causing impaired judgement’ and makes a ‘counseling referral’ (ORS 127.825 § 3.03)” (Johnson, Cramer, Conroy, & Gardner, 2013, p. 583).
Nurses are prohibited by law and by the professional nursing code of ethics to participate in PAD. Nurse practitioners’(NP) scope of practice continues expanding. Some states identify a nurse practitioner as a primary care provider and have the ability to practice independently without a physician’s oversight. NPs play a role in disease prevention, health management and health promotion. There are more than 20 states currently allowing NPs to diagnose, treat and prescribe medication without physician oversight (Simmons School of Nursing and Health Science, 2016, para. 3). In all states where PAD is legal, NPs are prohibited from diagnosing a terminal condition for participation in PAD or prescribing the medication used in PAD (Stokes, 2017, p. 152). There is currently a pending bill in the New York State Assembly that could allow NPs to participate in PAD. New York Bill No A10059, the Medical Aid in Dying Act, introduces the idea of allowing NPs to participate in PAD only if they qualify as a mental health professional by training, clinical expertise, or certification. New York would be the first state in the US allowing NPs to participate in PAD. This raises an ethical dilemma for NPs because of the professional Code of Ethics for Nurses against any participation with accelerating one’s death (Stokes, 2017, p.152). The American Nurses Association (ANA) also does not support PAD and prohibits nurses’ involvement in the practice.
As primary care providers in states where PAD is legal, NPs and patients who want to continue a provider to patient relationship throughout the patient’s life spectrum, including end-of-life decisions, face unnecessary ethical and moral dilemmas. NPs are faced with a problem when approached by their patients about PAD. If NPs have the legal authority in their state to practice independently without a physician’s oversight and practice in a state in which PAD is legal, the NP should be allowed to participate in their patient’s decision to engage in PAD.
Statistics
PAD is still a fairly new concept in the United States. There are those that oppose the practice of PAD, but statistics show that the majority of the population supports the concept. A 2017 Gallup poll indicates that 73% of Americans support a terminally ill patient choosing to end their life by utilizing PAD (Wood & McCarthy, 2017, para. 1). Since the passage of the DWDA in Oregon 20 years ago, data indicates that of those who received a prescription for PAD, 2/3 died from ingesting the medication. In 2016, 204 prescriptions for PAD were written in Oregon under the DWDA, 133 of those individuals ingested and died from the PAD medication. The majority of the patients who choose to die from the prescribed medication are married, white males who are college educated, over the age of 65, and diagnosed with terminal cancer (Oregon Health Authority, 2017, para. 3). In 2015, data from Washington state indicated that 3/4 of individuals who received a prescription for PAD died from ingesting the medication (Stokes, 2017, p. 151).
The nurse’s role in PAD is a controversial topic. Over the past 20 years that PAD has been legal in the states, studies have shown that 1%-18% of nurses have intentionally prescribed or provided drugs to a patient knowing their intentions were to use the drug to accelerate their death or intentionally injected drugs to accelerate a patient’s death. Studies show that approximately 17%-40% of hospice and intensive care nurses have been approached by patients to quicken their death to end their suffering (Stokes, 2017, p. 150). It is fairly known that nurses are often at their patients’ bedside providing close care. Nurses are often the first line of care and known advocates for their patients. Despite nurses’ prohibitions and restrictions, studies show that some nurses are already actively participating in PAD. Statistics indicate that with nurses’ close involvement in bedside care and the increasing support of Americans in favor of PAD, nurse governing bodies and legislators should carefully reconsider their current position on prohibiting nurses from participating in PAD.
Critique of ANA’s Position on PAD
The American Nurses Association (ANA) position statement on PAD, which they refer to as assisted suicide, strictly prohibits nurses from participating in hastening a patient’s death at end-of-life. The ANA’s reasoning is vague and provides little explanation for their disapproval. Their reason for disapproval is that involvement in PAD violates a nurse’s ethical duty in promoting and restoring health. They do not clearly define the responsibilities of nurses in PAD. The ANA position statement is as follows:
The American Nurses Association (ANA) prohibits nurses’ participation in assisted suicide and euthanasia because these acts are in direct violation of Code of Ethics for Nurses with Interpretive Statements, the ethical traditions and goals of the profession, and its covenant with society. Nurses have an obligation to provide humane, comprehensive, and compassionate care that respects the rights of patients but upholds the standards of the profession in the presence of chronic, debilitating illness and at end-of-life (American Nurses Association [ANA], 2013, para. 3).
A nurse’s participation in PAD is a direct violation of the Code of Ethics for Nurses Interpretive Statement 1.4, which states:
The nurse should provide interventions to relieve pain and other symptoms in the dying patient across the continuum of care and consistent with palliative care practice standards and may not act with the sole intent to end life (ANA, 2013, para. 6).
The ANA’s disapproval against PAD is vague and weak. They reiterate a nurse’s obligation to provide comfort and alleviate a patient’s suffering, which by no means is incorrect, but they offer little guidance for nurses residing in states which have legalized PAD. If a nurse is faced with a patient requesting PAD, there are limited resources available to assist a nurse in providing sufficient and reliable information on the matter. The ANA vaguely states a nurse’s responsibility in the matter. It is evident that PAD is becoming more of a legalized act in the United States and nurses should have reliable sources available to them to provide unbiased information to their patients. Nurses are taught to be unbiased when it comes to religion, culture and race, but when it comes to a patient’s wishes at their end-of-life, nurses are being guided towards disapproving their wishes.
Pros and Cons
There is different moral, legal and ethical reasons behind a critic or advocate’s position on the participation of nurses and NPs in PAD. The ANA clearly prohibits nurses from actively participating in PAD, but there are also those that support a nurse’s involvement in PAD if their patient requests it. There are pros and cons to nurse involvement in PAD. They are as follows:
1. Cons
a. According to ANA, Nurses who participate in PAD are committing actions that are in direct violation of the code of ethics. Participating in something with the sole intent of ending a life is prohibited and illegal.
b. Gallup statistics show that people who regularly attend church support PAD less than people who do not attend church. Gallup discussed how people may argue that PAD is taking a person's life out of God’s hands and placing it in a physician's hands (Wood & McCarthy, 2017, p.3)
c. PAD allows the physician to determine whether or not the individual will die within six months (O’Rourke, O’Rourke, & Hudson, 2017). The physician’s diagnosis could put the patient in a vulnerable state.
d. Similar to any law, there is the chance of PAD being abused. PAD has the potential to be misused by physicians, patients, and even nurses. Since PAD has been ruled a state decision, criteria and regulations could differ from state to state. Unclear regulations regarding PAD increases the potential for loopholes and confusion, which could place all healthcare workers in a legal predicament.
e. There are some that argue, “allowing an exception to society’s long-standing prohibitions against assisting suicide or directly causing another’s death is immoral, would severely erode trust in clinicians, and/or would facilitate justification for ending the life of vulnerable persons” (De Lima, Woodruff, Pettus, Downing, Buitrago, Munyoro, & … Radbruch, 2017, p. 9).
2. Pros
a. One of the reasons patients seek out PAD is to reduce their pain and suffering related to their diagnosis. There are many incurable diseases that can cause a patient discomfort and suffering for months to years. PAD allows the patient to avoid a painful death (Stokes, 2017).
b. PAD allows the patient to have control over when and where they die. Oregon Health Authority statistics show that 88% of patients that use PAD die in the comfort of their own home (2017). This allows the patient to die in an environment they feel comfortable in and around people of their choosing.
c. According to VGAvirginia.org, an important benefit to PAD is the conservation of organs. As a patient begins the transition into end of life, their organs begin to diminish and function decreases (13 Pros and Cons, 2015). The use of PAD allows for the conservation of organs, which could extend and enhance another individual’s life.
d. Battling a life-threatening disease or cancer can have a financial toll on the patient. If a patient chooses PAD, it could relieve the family or kin from the financial burden of life sustaining treatment at end-of-life.
e. If a NP was legally able to participate in PAD, it would allow the NP to promote the patient’s well-being entirely. If a patient requests PAD and the practice is legal in their state, a NP should be allowed to respect the patient’s wishes and provide for autonomy.