July 2007, Volume 34, Number 4

 

Oncology Nursing Society Position

Nurses’ Responsibility to Patients Requesting Assistance in Hastening Death

 

 

Despite significant advances in the multidisciplinary approach of palliative care and the growing body of evidence-based practice, a multitude of variables continue to interfere with excellence in end-of-life care for everyone. The Oncology Nursing Society (ONS) recognizes the critical need for continued reform and advocates for quality care across the illness continuum. ONS recognizes the intellectual and psychosocial contributions of nursing care, supports continued efforts to improve compassionate, evidence-based care for the dying, and encourages continued dialogue on any and all ethical dilemmas. “The central axiom that directs the nursing profession is respect for persons. The principles of autonomy (self-determination), beneficence (doing good), nonmaleficence (avoiding harm), veracity (truth-telling), confidentiality (respecting privileged information), fidelity (keeping promises) and justice (treating persons fairly) are all understood in the context of the overarching commitment to respect for persons” (American Nurses Association [ANA], 1994).

 

Individual nurses may encounter agonizing clinical situations and experience personal and professional tension and ambiguity surrounding a patient’s request for hastening death (Volker, 2001). Requests for assistance in hastening death are not uncommon for healthcare professionals treating patients with advanced cancer and other life-limiting illnesses. The issue has engendered intense debate in medical, legal, bioethical, and lay communities. Currently, withholding or withdrawing treatment, the use of sedation to relieve intractable distress in the terminally ill, and withholding nutrition and hydration are legally sanctioned. “Honoring the refusal of treatments that a patient does not desire, that are disproportionately burdensome to the patient, or that will not benefit the patient is ethically and legally permissible. Within this context, withholding or withdrawing life-sustaining therapies or risking the hastening of death through treatments aimed at alleviating suffering and/or controlling symptoms are also legally and ethically acceptable. There is no ethical or legal distinction between withholding or withdrawing treatments, though the latter may create more emotional distress for the nurse and others involved” (ANA, 1994). The Oregon Death With Dignity Act (ORS 127.800) allows Oregon citizens who meet strict criteria the right to hasten their own deaths. The statute, pertinent only to Oregon, has taken the debate to wider circles and triggered a multitude of initiatives to improve end-of-life care across the country. For purposes of this position statement, hastened death is a request from a patient with a progressive, incurable illness, and whose judgment is not impaired, for intervention(s) that would cause death to occur more immediately rather than allowing the illness to take its natural course.

 

It Is the Position of ONS That

 

  A terminal illness can cause intense physical symptoms as well as fear of unrelieved symptoms. Individuals may experience depression and hopelessness and fear the loss of control over themselves and their environment. A potential “loss of self” requires that the dying are cared for by compassionate, sensitive, and knowledgeable professionals who will attempt to identify, understand, and meet individual needs.

  Physical suffering may not always be alleviated, and only a dying individual can judge what is a tolerable or acceptable level of personal suffering. Nevertheless, nursing is charged with supporting the ethical mandates of the profession while simultaneously seeking to understand the meaning behind the request for hastening death.

  A request for hastening death prompts a frank discussion of the rationale for the request, a thorough and nonjudgmental multidisciplinary assessment of the patient’s unmet needs, and prompt and intensive intervention for previously unrecognized or unmet needs.

  Nurses refrain from using judgmental language in the presence of patients, family members, significant others, and professional colleagues when hastened death is requested.

  Nurses have the right, on moral and ethical grounds, to refuse to be involved in the care of patients who choose hastened death as a course of action, even in jurisdictions where patients are allowed to hasten their own deaths by taking legally prescribed medication. When a request for hastened death is made, nurses listen compassionately, resist the inclination to abandon (i.e., withdraw physically or emotionally from patients), and explain that they are unable to provide assistance. This does not constitute abandonment. In those circumstances, however, care must continue until alternative sources of care are available to patients. Those who choose to continue care may remain with patients if patients and nurses are comfortable with the arrangement (Oregon Nurses Association, 2001).

 

References

 

American Nurses Association. (1994). Assisted suicide [Position statement]. Retrieved January 2, 2007, from http://nursingworld.org/readroom/position/ethics/etsuic.htm

 

Oregon Nurses Association. (2001). ONA provides guidance on nurses’ dilemma. Retrieved January 2, 2007, from http://www.oregonrn.org/associations/3019/files/AssistedSuicide.pdf

 

Volker, D.L. (2001). Oncology nurses’ experiences with requests for assisted dying from terminally ill patients with cancer. Oncology Nursing Forum, 28, 39–49.

 

Approved by the ONS Board of Directors 1/01; revised 11/02, 7/04, 1/07.

 

To obtain copies of this or any ONS position, contact the Customer Service Center at the ONS National Office at 125 Enterprise Drive, Pittsburgh, PA 15275-1214 (866-257-4ONS; customer.service@ons.org). Positions also may be downloaded from the ONS Web site (www.ons.org).