Oncology Nursing Society Position on 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 continues 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, including the alleviation of pain and the provision of quality palliative care. A terminal illness can cause intense physical symptoms as well as fear of unrelieved symptoms. Patients may experience depression and hopelessness and fear loss of control over themselves and their environment. Physical, emotional, and spiritual suffering may not be alleviated, and only the dying person 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 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.
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).
Requests for assistance in hastening death are not uncommon for healthcare professionals treating patients with advanced cancer and other life-limiting illnesses. 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 knowingly and intentionally cause death to occur more immediately rather than allowing the illness to take its natural course.
Healthcare providers may encounter agonizing clinical situations and experience personal and professional tension and ambiguity surrounding a patient's request for hastening death (Ferrell & Coyle, 2008; Quill & Arnold, 2008). 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 also are legally and ethically acceptable. No ethical or legal distinction exists between withholding or withdrawing treatments, though the latter may create more emotional distress for the nurse and others involved (ANA, 1994).
A few states have enacted legislation that allows citizens who meet strict criteria with the legal right to hasten their own deaths.
It Is the Position of ONS That
- Dying persons are cared for by compassionate, sensitive, and knowledgeable professionals who attempt to identify, understand, and meet their individual needs, particularly in the case of fear or a sense of hopelessness or loss of control.
- Alleviation of pain and other serious symptoms must be a key priority in providing quality palliative care.
- Although ONS does not support procedures or actions whose direct and immediate purpose is to cause a person's death,it 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.
- Requests for hastening death prompt 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 share relevant information about health choices that are legal and support the patient and family regardless of the decision the patient makes.
- In those jurisdictions where patients are allowed to hasten their own deaths by taking legally prescribed medication, 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. When a request for hastened death is made, nurses opposed to participation in such activities must 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 (Oregon Nurses Association, 2001).
Approved by the ONS Board of Directors 1/01; revised 11/02, 7/04, 1/07, 1/10.
References
American Nurses Association. (1994). Assisted suicide [Position statement]. Retrieved from http://www.nursingworld.org/position/ethics/suicide.aspx
Center for Health Statistics, Washington State Department of Health. (2009). Death With Dignity Act. Retrieved from http://www.doh.wa.gov/dwda/
Ferrell, B.R, & Coyle, N. (2008). The nature of suffering and the goals of nursing. Oncology Nursing Forum, 35(2), 241-247. doi: 10.1188/08.ONF.241-247
Oregon Nurses Association. (2001). ONA provides guidance on nurses' dilemma. Retrieved from http://www.oregonrn.org/associations/3019/files/AssistedSuicide.pdf
Quill, T., & Arnold, R.M. (2008). Evaluating requests for hastened death. Journal of Palliative Medicine, 11(8), 1151-1152. doi: 10.1089/jpm.2008.9848
The ONS position "Nurses' Responsibility to Patients Requesting Assistance in Hastening Death" was recently reviewed and revised by the ONS Board of Directors with input from end-of-life experts and the ONS Ethics Special Interest Group. The statement continues to emphasize the alleviation of pain and the provision of quality palliative care as the key responsibility of the oncology nurse. The revised statement notes that "Although ONS does not support procedures or actions whose direct and immediate purpose is to cause a person's death, it recognizes the intellectual and psychosocial contributes 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." As additional states consider legislative and judicial changes that allow for assistance in hastening a patient's death, nurses are encouraged to share relevant information about health choices that are legal and support the patient and family regardless of the decision the patient makes. "Inthose jurisdictions where patients are allowed to hasten their own deaths by taking legally prescribed medication, nurses have the right to refuse to be involved in the care of patients who choose hastened death as a course of action, however, care must continue until alternative sources of care are available to the patient."