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Life-Terminating Choices:
A Framework for Nursing Decision-Making
Prepared by The Task Force on Resolution
#9
Introduction
During the 1990's, assisted suicide has become the
subject of public debate and legislative action across the nation.
In 1997, the U.S. Supreme Court is reviewing two critical Circuit
Court decisions involving the legalization of physician-assisted
suicide. These are matters for serious examination by all health
care providers, because they call into question the ethical standards
and legal bases for practice. It is important for nurses and professional
nursing organizations to articulate and clarify the nursing values
that are relevant to this crucial question.
Annotated
Bibliography
Resources
NLN Resolution #9
Press Release: - White Paper on Assisted Suicide Life-Terminating
Choices: A Framework for Nursing Decision-Making.
At the 1995 NLN Biennial Convention, the following
resolution was adopted: That the National League for Nursing establish
a Task Force to examine the moral, ethical, and legal dimensions
of the nurse’s role in responding to patients who make life-terminating
choices under conditions of futility. (The full text of this resolution,
along with the names and affiliations of Task Force members, is
included here in appendices.) After completing a comprehensive study,
the Task Force has assembled this document and a related annotated
bibliography.
The goal of the Task Force in compiling these materials
is to offer some parameters for individual and collective decision-making,
and to stimulate discussion and debate within the nursing community.
While neither the Task Force nor the NLN has taken a position on
assisted suicide, we recognize that other major nursing organizations,
including the American Nurses Association1 and the American Association
of Critical Care Nurses,2 are explicit in their opposition to nurses’
involvement in this practice. Given the range of life-terminating
choices, it is our belief that a single position on the part of
this organization would not be helpful at this time. It seems more
appropriate to put forth considerations that can be used as a kind
of heuristic in addressing various situations. Whatever our individual
or organizational positions on assisted suicide, it is clear that,
if legalized, there will be far-reaching effects on nursing practice.
At this time, then, it is essential for nurses to explore the issues
involved.
Definitions
The term "life-terminating choices" was
used in the resolution to foster the broadest possible discussion
of end-of-life decision-making. Scanlon and Rushton suggest that
assisted suicide be regarded as part of a continuum of end-of-life
choices, "including do-not-resuscitate decisions, interventions
to manage pain and symptoms, use of life-sustaining therapies, withholding
or withdrawing medically provided nutrition and hydration, and active
euthanasia."3 The challenge for nurses, they note, is to understand
the distinctions and subtleties between these choices as we explore
the ethics of our responses.
There is some disagreement in the literature over
the meanings of terms frequently used in these discussions. This
report assumes the definitions that are most widely accepted. Assisted
suicide means providing a patient with the means to end his or her
life -- for example, by deliberately prescribing large quantities
of a drug which can be lethal in high doses. Active euthanasia requires
the active participation of the physician (or other provider), whose
intervention will directly cause the patient’s death -- such as
via the intravenous administration of potassium chloride or a high
opiate dose.
The term passive euthanasia is sometimes used to
refer to appropriate decisions about the refusal, withholding, or
withdrawal of life-sustaining treatment, or the administration of
pain relief which could incidentally hasten a patient’s death. We
find "euthanasia" to be an inappropriate term when used
to describe these medically and legally-sanctioned actions, and
therefore do not refer to these actions when using the term "euthanasia"
here.
Nursing Roles and Relationships
Of all health care providers, nurses are the ones
found in virtually every care setting, and ours is often a 24-hour
presence. Our relationships with patients under these circumstances
are often close and not infrequently long-term. Because of the nature
of these relationships and the values most nurses share, we are
in a unique (and perhaps uncomfortable) position as questions of
assisted suicide are considered. Values and characteristics integral
to nurse-patient relationships are highlighted in the discussion
below.
There are circumstances in which medical treatment
and therapy cannot reverse or correct the patient’s illness and/or
suffering. For reasons of dignity and comfort, some patients may
request assistance in dying. Historically, nurses are intimately
involved with patients, as well as with patients’ families and friends.
In this privileged role, nurses frequently listen to patients express
their innermost fears and anxieties. Given this closeness between
patient and nurse, it appears likely that patients will feel "safe"
expressing a desire to end their life to a nurse. In addition, nurses
could be asked to participate in procedures which would hasten the
death of a patient who has decided that death is preferable to life.
Nurses have a particular appreciation for the uniqueness
of each individual. Most nurses have had the opportunity to meet
and learn from many different kinds of people, and this tends to
foster a greater understanding of the richness of diversity as well
as an appreciation for each person’s unique individuality. This
understanding probably contributes to the dissonance many nurses
feel when confronted with emotionally-charged issues like assisted
suicide. We can often see exactly why a particular patient might
make such a choice, even when we ourselves might be strongly opposed
to it.
Nurses traditionally have a commitment to preserve
and honor each patient’s dignity and personal choices. Because of
the deep relationships established between patients and nurses,
nurses are able to appreciate the values and meanings about life
that are important to those individuals -- even when those values
conflict with the nurse’s own personal beliefs and values.
The compassionate relief of suffering is a central
aspect of nursing. Our intimate and extended exposure to intense
suffering, often in situations where we perceive that other providers
or "the system" are unresponsive to that suffering, makes
us particularly conflicted about arguments regarding assisted suicide
as a remedy for suffering.
Within the nurse-patient relationship, the nurse’s
role includes serving as the patient’s advocate, comforter, supporter,
facilitator, educator, communicator, and confidante. The enactment
of these various roles results in the nurse’s establishment of an
authentic caring relationship with the patient. The nurse also serves
as coordinator of the overall health care plan, and is often a liaison
between the patient, family, and members of the health care team.
Support for, participation in, or opposition to assisted suicide
are issues interwoven within each of these roles. Each role represents
a privileged aspect of the nurse-patient relationship, and each
brings with it a responsibility for thoughtful and individualized
application.
End-of-life decision-making is not confined to institutional
environments. With more and more care being rendered in the community
and in the patient’s home, nurses in all practice settings are confronting
these concerns. In addition, professional boundaries in relationships
with patients who are cared for in their own homes are often blurred.
The debate
Arguments for and against assisted suicide are detailed
in the literature. (See attached annotated bibliography.) Points
for and against the legalization of this practice encompass legal,
ethical, religious, and medical arguments. These are very briefly
summarized here. The slightly longer list of arguments against assisted
suicide should not be taken as a suggestion of a "position
statement" by this Task Force, but simply another indication
of the complexity of the issues involved.
Arguments FOR the legalization of assisted suicide
include:
The freedom to control one’s own body (autonomy,
self-determination) is a fundamental right, and individuals
should have a "right to die."
The values of individual well-being and compassion
for suffering mandate that we end suffering when we are able
to do so.
The distinction between withholding or withdrawing
treatment in futile situations and directly ending a life is
often not meaningful. Because withholding or withdrawing treatment
under conditions of futility is legally permissible throughout
the U.S., and medically accepted by most, proponents argue that
society should also sanction assisted suicide under these conditions.
Assisted suicide is already taking place. Allowing
the practice to continue in secret leaves providers isolated,
without the advice of colleagues or ethics committees, and without
public accountability for their actions. Legalization, then,
would help ensure that assisted suicide is used compassionately
and appropriately.
Legalization is necessary to ensure medical
safeguards and to make it equally available to all who want
it. Proponents wish to avoid botched "back-alley suicides"
equivalent to "back-alley abortions." (Others note
that this necessarily erodes the privacy of the provider/patient
relationship, exposing both to criticism and attacks on personal
safety similar to those that have surrounded acts of abortion.)
Arguments AGAINST the legalization of assisted
suicide include:
Legalization begins a "slippery slope"
process that will inevitably lead to nonvoluntary, active euthanasia
of patients who may or may not be terminally ill.
Legalization will subject people who are elderly,
disabled, or otherwise disenfranchised in our society to subtle
social pressures to die in order to relieve a perceived social,
economic, and emotional burden on others. Those opposed for
this reason say that assisted suicide might be workable in another
society, but that it is a dangerous move in the U.S., given
the current context of for-profit managed care, cost containment,
clinical decisions made by non-clinicians, and growing social
inequities.
The medical/nursing value to "do no harm"
irrevocably forbids any deliberate act to cause death. Many
feel that the legalization of assisted suicide will erode the
devotion of physicians and nurses to their patients’ best interests,
and that it is not a medical or nursing role to decide which
life is worth living. Opponents also raise concerns about the
possible proliferation of "suicide mills," or of clinicians
drawn to the practice by power or ego considerations instead
of compassion.
The legalization of assisted suicide diverts
attention away from the need to optimize palliative care. Hospice
care remains unavailable to many because of the scarcity of
programs, the refusal of some insurers to cover it, the lack
of medical and nursing training in palliative care, and the
public’s lack of familiarity with advanced directives and with
what palliative care can accomplish. Many hold that expert pain
management, aggressive treatment of other symptoms, and attention
to the patient’s and family’s physical and psychosocial needs
would eliminate the need for assisted suicide -- that "unmanageable"
suffering is too rare to call for a change in public policy
on these grounds.
Just because an act may be morally acceptable
to many does not mean that it is sound public policy. This argument
is related to the "slippery slope" argument, and points
up the complex relationship between individual moral choice
and public policy. Jennings, in his discussion of active euthanasia,
notes that he is "sympathetic to the tragedy in individual
cases and not at all ready to condemn those who choose to end
their life or those who support them in this choice. But at
the same time I am opposed to a public endorsement and a public
legitimization ....as I doubt the ability of our health care
system to practice euthanasia humanely and without substantial
abuse..."4
Euthanasia circumvents the grieving process,
thereby taking away meaning from death and making the survivor’s
healing more difficult.
A Framework for Ethical Decision-Making
There are moral or ethical issues involved when
patients request assistance with dying. Because of the trust developed
between each patient and nurse, and between society and the nursing
profession, it is important for each professional nurse to examine
these issues.
When a nurse’s personal values conflict with the
patient’s decision to terminate life, the nurse has the right (after
making the appropriate referral) to withdraw from further participation
in the care of the patient. When a nurse’s personal values are consistent
with a patient’s choice to terminate life, the nurse should carefully
consider the implications of any actions which may hasten or delay
the patient’s death. In addition, in all situations in which a nurse
is aware that a patient is contemplating a life-terminating action,
the nurse has an obligation -- to her- or himself, to the patient,
to the family, to other health team members, to the profession,
and to society - to encourage thorough and informed communication
among all involved parties.
The patient’s interests and respect for the patient
are at the core of ethical caring. The nursing profession has standards
of conduct which provide guidelines for practice and a framework
for developing a moral philosophy or ethic of caring. An "ethical"
nurse is one who conforms to given standards of conduct.
The principles of trust, beneficence (to do good),
justice (equality), veracity (truth-telling), informed consent (knowledge
of all options), confidentiality (privacy), fidelity (true to promises),
autonomy and inalienable rights (self-determination), nonmaleficence
(do no harm), and a care orientation (attention and response to
needs within the context of a given situation) serve as a basis
for the ethic of caring. These principles are integrated into nurses’
beliefs, thinking, and judgments during the professional socialization
process, and nurses use them to develop an internalized sense of
right and wrong, and of acceptable versus unacceptable behavior.
With this basis for ethical practice and with experience,
nurses increase their understanding of the meanings of responsibility,
obligation, and accountability. Personal beliefs and feelings are
acknowledged, clarified, and affirmed.
Today, with increasing debate about assisted suicide,
the nurse’s ethic of caring needs to be re-examined as it applies
to terminally ill patients. Honest self-exploration is essential
if each nurse is to understand the influence of his or her own personal
beliefs on clinical encounters and decision-making. It is not the
desire of Task Force members to prescribe one position or another
for nurses to take on this issue; we offer the following line of
inquiry for the nurse’s consideration of assisted suicide and how
it will affect her/his practice.
Personal values clarification
Is assisted suicide a quality-of-life issue?
What are my values and beliefs about assisted
suicide?
What are the values and beliefs of my profession?
Of other health-related professions? Of my employer?
What is the position of my state board of nursing?
Do I have an ethics review board from whom I
can seek information? What are their values and beliefs?
What are the values and beliefs in my community?
What are the values and beliefs of the state
and national legislatures?
Has my state passed any laws related to physician-assisted
suicide? Are there any bills before my state legislature?
What is happening internationally on this issue?
Am I willing to take a stand on this issue?
Am I willing/able to affirm my stand publicly
in some way - as a panel member, social activist, or leader
in my place of employment?
Related Actions
What seems to be in the best interest of the
patient?
What is my professional obligation and responsibility
depending upon the stand I take?
If assisted suicide were legalized and I oppose
it, what care am I willing to provide? If I am not opposed,
what exactly am I willing to do? Nursing actions might include:
Provide care and comfort
Explore the reasons for the patient’s request
Inform the patient of all available legal options
Explain the law
Encourage the patient to communicate openly with
family and significant others about his or her plans
Encourage the patient to make appropriate plans
- for a funeral or memorial service, if desired; for the family’s
future; etc.
Inform the patient about available community resources
Maintain confidentiality about the patient’s decisions
Assist the patient in obtaining prescribed drugs
Be present during the patient’s self-administration
of medication, during death, and afterwards to console significant
others who may be present
Assist the family and significant others in arranging
long-term bereavement support
Provide care to a patient admitted to the emergency
room after a failed (assisted) suicide attempt
Conscientiously object to direct involvement, and
refer the patient to another health care provider
Be involved in policy development at one’s health
care facility, community agency, or local government body
As nurses consider these options, the value of an
organized ethics committee in all health care settings -- within
home health care agencies and community settings, as well as in
inpatient settings -- cannot be overemphasized. Nurses often practice
very independently and with a great deal of autonomy. Peer support
may be lacking in some settings, and the nurse may feel isolated.
This can create situations where the nurse feels vulnerable and
subject to the influence of others.
Nurses should also have the benefit of clear lines
of authority, appropriate resource persons, and explicit clinical
protocols concerning life-terminating deliberations of the patients
in their care. Support groups involving other health professionals
can serve as a vehicle for the nurse to express feelings, frustrations,
and grief.
Each nurse’s process of self-exploration contributes
to personal growth and to sound, ethical decision-making in the
clinical setting. In addition, careful consideration of the issue
can strengthen and affirm nursing’s voice in these matters. The
issue of assisted suicide raises significant questions for society,
for individual patients, and for members of the health professions.
Because of nurses’ deep familiarity with the dying process and with
death, our experience and nursing values regarding end-of-life care
add an important perspective to the public debate.
Footnotes
1. See ANA Position Statement on Assisted Suicide
(December 8, 1994). American Nurses Association, Washington, DC.
2. Scanlon, C. & Rushton, C.: Assisted suicide:
Clinical realities and ethical challenges. AMER J CRIT CARE 1996
(Nov); 5(6):397-403.
3. Ibid, p. 400.
4. Jennings, B.: Active euthanasia and forgoing
life-sustaining treatment: Can we hold the line? J OF PAIN &
SYMPTOM MGMENT 1991; 6(5): 312-316.
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