Life-Terminating Choices:
A Framework for Nursing Decision-Making

NATIONAL LEAGUE FOR NURSING

Annotated Bibliography

Alpers, A and Lo, B: Physician-assisted suicide in Oregon: A bold experiment. JAMA 1996; 274(6):483-487.

An analysis of the provisions of the Oregon law and a discussion of the specific questions it raises for physicians, nurses, and pharmacists. Included: the "quick fix" of a suicide prescription versus the more difficult work of palliative care; the implications of moving beyond the scope of the law; the psychological dangers to the patient when physician rather than patient suggests assisted suicide as an option; and the problems in determining (and ingesting) a drug dose certain to be lethal.
Asch, D.A.: The role of critical care nurses in euthanasia and assisted suicide. New Engl J Med 1996 

(May 23); 334(21):1374-1379.

This research report received a great deal of sensationalized news coverage when it was published. Asch surveyed 852 U.S. nurses who work in adult ICUs, and found that 16 percent reported involvement in acts of assisted suicide. This research has been criticized for not clearly differentiating among euthanasia, assisted suicide, and withdrawing/withholding treatment in the survey questions. Nevertheless, the nurses’ responses, including written comments, illustrate our intimate involvement in end-of-life situations, and suggest that at least some nurses, when confronted with patients’ intense suffering, are taking action on their own.Baron, C.H. et al: A model state act to authorize and regulate physician-assisted suicide. Harvard J on Legislation 1996; 33:1-34.

This legal article was written by a committee of attorneys, physicians, and ethicists. It is divided into four sections: an introduction that sets a framework for discussion within the context of current law and current thinking in medicine and philosophy; a review of the committee’s difficult deliberations on the subject; a discussion of Constitutionality issues; and a detailed overview of the provisions of their proposed statute. An interesting discussion from a legal perspective.Chochinov, H.M. et. al.: Desire for death in the terminally ill. Amer J Psychiatry 1995 (Aug); 152(8): 1185-1191.

Semistructured interviews with 200 terminally ill inpatients investigated the prevalence of their desire for death, the stability of this desire over time, and its association with clinical depression. The researchers found that 8.5 percent of these people evidenced a "serious and pervasive" desire to die, and that this desire was correlated with ratings of pain, low family support, and (most significantly) with measures of depression.

Davis A.J. et. al.: Nurses’ attitudes toward active euthanasia. Nursing Outlook 1995; 43:174-79.A discussion of nurses’ attitudes, their reasons for opposing or supporting euthanasia, and the conditions necessary for them to participate in active euthanasia. Data from 80 U.S. nurses were obtained from a larger, descriptive study of nurses in seven countries who are experts in dementia care or cancer care. While overall, 21 percent of these nurses said they supported active euthanasia, it is of interest to note that 25 percent of the nurses interviewed were ambiguous or self-contradicting in their answers - pointing up the need for nurses to more fully develop their personal ethical explorations on the subject.deWachter, MAM: The Dutch and dying. Hastings Cr Rep 1991 (Nov-Dec).
The director of an institute for bioethics in the Netherlands summarizes the Remmelink Commission studies of physicians’ practices in end-of-life care. Among the findings were: that family physicians are the ones most often involved in decisions about euthanasia; that approximately 9000 patients annually request euthanasia, and about 2300 receive it; and that physicians assisted patients in about 400 of these cases. The studies also explored end-of-life decision-making in four special categories of patients: newborns with severe congenital anomalies; children with fatal illness; psychiatric patients; and people with AIDS.Drane, J.F.: Physician assisted suicide and voluntary active euthanasia: Social ethics and the role of hospice. Amer J of Hospice and Palliative Care 1995 (Nov-Dec): 3-10.

Thought-provoking discussion (in the context of the recent Circuit Court decisions, Biblical history, and the hospice movement) of several ethical questions, including: What is the relationship between individual morality and public morality? How do we balance individual needs with community needs? When do legalized small exceptions to proscriptive law make society more (or less) humane? Does majority support by itself justify a change in public policy? What kind of society would result from the legalization of assisted suicide?

Euthanasia debate (letters). Br Med J 1995; 310:1466-67.

Thoughtful perspectives on euthanasia and physician-assisted suicide, including discussions of: the "slippery slope" to nonvoluntary euthanasia; good palliative care as an alternative; the great need to update physicians’ knowledge and skills in palliative care; the question of whether a physician is needed at all in assisted suicide; arguments for autonomy and patient choice; "respect for life" versus "respect for a life;" and the potential of legalized suicide to increase openness in the doctor-patient relationship.Fins J.J., Bacchetta M.D.: The physician-assisted suicide and euthanasia debate: An annotated bibliography of representative articles. J of Clinical Ethics 1994; 5(4):329-340.

These detailed notes on 24 articles, most from the medical literature, provide an excellent overview of the questions raised in discussions of assisted suicide and euthanasia. Various perspectives are presented, offering a thought-provoking introduction to the issues. If someone wanted to learn about these issues but had little time to study the literature, this would be the one article to read.

Holden C.M.: Easing the burden of decision-making in futile situations. HEC forum 1995; 7(5): 322-330.

A description of the use of Allow Natural Death (AND), a directive approach to end-of-life decision-making. This article includes a thought-provoking discussion of whether CPR should be presented as an option (thereby increasing the decision-making burden on family) in cases in which it is unlikely to provide any benefit. "Respect for autonomy does not require that physicians initiate discussion of pointless medical procedures."

Jecker NS: Medical futility and care of dying patients. In Caring for Patients at the End of Life (Special Issue), Western J Med 1995; 163: 287-291.

The author notes that "futility" refers to a specific medical intervention applied to a specific patient at a particular time -- not to a situation generally. She delineates various ethical responsibilities regarding medical futility, including good communication, resolving personal conflicts, and developing professional standards. The article ends with a discussion of what compels patients and families to insist that "everything be done," and what drives practitioners to do the same.

Kowalski S.: Assisted suicide: Where do nurses draw the line? Nursing & Health Care 1993 (Feb); 14(2): 70-75.

A brief history of the question of assisted suicide, with reference to a few pertinent articles from the literature, the Dutch experience, and the Hemlock Society. The author then discusses some ethical dangers of assisted suicide, from her own stance of strong opposition to active euthanasia.

Lee M.A., Tolle S.W.: Oregon’s plans to legalize suicide assisted by a doctor: How much more open will the practice become? Br Med J 1995; 310:613-614.Interesting thoughts from a physician and an ethicist from Oregon Health Sciences University. They point out the narrow margin by which Oregon voters approved of the new law, and the clear message the vote sends regarding grave public dissatisfaction with end-of-life care. Also addressed is the concern of physicians that any "legal" right to assisted suicide may be challenged, violently, by right-to-life advocates via the kinds of harassment endured by MD’s who perform abortions.New York State Task Force on Life and the Law: New York advises on assisted suicide. Bull Med Ethics 1994 (Aug); 8-11.

This is the slightly abridged summary of a large report on euthanasia and assisted suicide. While Task Force members apparently had different perspectives on these issues, they unanimously concluded that the danger of a change in public policy (to legalize assisted suicide) outweighs any possible benefits. This piece is a detailed and thought-provoking discussion of the ethical issues, social concerns, and medical issues that informed their decision.

Paquette S.: Oregon’s assisted suicide law. Am J Hospice & Palliative Care 1996 (Jan/Feb); 11-16.A discussion of Oregon’s 1994 law, which awaits Supreme Court review. That law allows only oral medication to be used, and mandates review by two physicians who will attest to the patient’s competence and lack of depression. The author, a hospice director, argues that public debate in Oregon was not well-rounded, and that proponents of the measure appealed to public fears of powerlessness in terminal illnesses. The article describes how the author’s hospice team explored the issues, and how they communicated their concerns to the public.Position of the American Academy of Neurology on certain aspects of the care and management of the persistent vegetative state patient (with commentary). Neurology 1989; 39:123-126.

This statement may be of interest to those exploring end-of-life issues. Persistent vegetative state is clearly defined, and the bases for its diagnosis explained. This is followed by a detailed discussion of the issue of withdrawal of medical treatment, including the use of artificial nutrition and hydration.

Role of critical care nurses in euthanasia and assisted suicide (letters). N Engl J Med 1996; 335(13): 971 - 974.

Letters from nurses in response to the Asch article. Included is a brief report of a survey of 215 AIDS nurses in the San Francisco area in which 15 percent of the respondents reported assisting in a patient’s suicide. (The Asch study reported 16 percent.) Replies from Asch and Scanlon are also included here.Scanlon C.: Euthanasia and nursing practice: Right question, wrong answer. N Engl J Med 1996; 334(21):1401 - 1402.

This editorial, in the same issue of the Journal as the Asch report, is critical of Asch’s study design. Scanlon calls for more attention to end-of-life care, including improved education about symptom management, more research on the attitudes and practices of health professionals, and the development of effective mechanisms to address conflicts and promote ethical practices.Scanlon C., Rushton C.H.: Assisted suicide: Clinical realities and ethical challenges. Amer J Crit Care 1996 (Nov); 5:397-403.

A thoughtful and detailed look at nurses and nursing vis-a-vis the debate about assisted suicide. Reviews moral concerns in the overall debate, then focuses on specific nursing concerns. The authors offer guidelines for assessing the patient who is contemplating suicide, and take a close look at the nurse’s role when a patient requests assisted suicide. This is a key article for nurses to read and discuss.Slome L.R. et al: Physician-assisted suicide and patients with human immunodeficiency virus disease. New Engl J Med 1997 (Feb 6); 336(6):417-421.

This is a report of the responses of 118 physicians, all working with people infected with HIV, to survey questions regarding physician-assisted suicide. Assisted suicide was defined in the survey as "a physician providing a sufficient dose of narcotics to enable a patient to kill himself." Among the findings: These doctors reported a mean of 7.9 "direct" and 13.7 "indirect" requests from patients for assistance with suicide; 48 percent of the doctors said they would be likely to grant a patient’s request for assistance; and 53 percent said they had assisted a patient in this way at least once.Task Force on Physician-Assisted Suicide of the Society for Health and Human Values: Physician-assisted suicide: Toward a comprehensive understanding. Acad Med 1995; 70(7):583-590.
Taken from a report by the Society for Health and Human Values in McLean, VA. The first part of the article examines questions physicians should ask themselves before establishing a policy on assisted suicide. The topics explored (equally applicable to nurses) include the moral status of suicide, clinical and epidemiological aspects of suicide, the relevance of voluntary choice, the nature of professional duty, and social implications. The end of the article suggests questions that patients/consumers should contemplate before requesting suicide assistance.

Tilden V.P. et. al.: Decisions about life-sustaining treatment: Impact of physicians’ behaviors on the family. Arch Int Med 1995; 155:633-637.This study is based on semistructured interviews with 32 family members of ICU patients who died after treatments were withdrawn. None of the patients had had advance directives. The interviews explored physician and nurse behaviors that were supportive of the families, and those that increased the family’s decision-making burden.Uris, P.F.: The meaning of futility through conversation. HEC Forum 1995; 7(5):309-321.

Interviews that wrestle with the definition of medical "futility," assembled for the purpose of developing guidelines to determine futile or inappropriate medical care. Also: the importance of context; economic issues (such as, who determines costs and benefits?); psychosocial needs and physiological needs; futility as a value-laden word; and what are the real questions that precede a discussion/definition of futility?

Vernacchio L: Physician-assisted suicide: Reflections of a young doctor. America 1996 (Aug 31); 175(5):13-16.

A resident physician considers the possible legalization of physician-assisted suicide in the wake of rulings by the Ninth and Second Circuit Courts. He distinguishes between active, assisted suicide and the withdrawal of life support in terminal patients. (The Circuit Courts held that these actions are morally equivalent.) He describes assisted suicide as a "quick fix" solution to the complex systemic problem of very poor quality end-of-life care in the U.S. Vernacchio's greatest concern is that assisted suicide could become a matter of convenience in our society, "ridding us of our burden to care for the sick and helpless."

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