Role of the Nurse When Hastened Death Is Requested (Endorsed Position Statement, Hospice and Palliative Nurses Association)
This position statement is endorsed by ONS and was republished with permission from the Hospice and Palliative Nurses Association (HPNA).
Approved by the HPNA Board of Directors October 2011. This position statement reflects the bioethics standards or best available clinical evidence at the time of writing or revisions. Copyright © 2011 by the Hospice and Palliative Nurses Association. To obtain copies of HPNA Position Statements, contact the HPNA National Office at
One Penn Center West, Suite 425
Pittsburgh, PA 15276-0100
HPNA Mission Statement: To advance expert care in serious illness.
It is not uncommon for patients with advanced incurable disease to express a desire to hasten their death.1 Because of the intimacy that characterizes the nurse-patient relationship, nurses who care for terminally ill patients encounter ethically challenging issues, including requests for assistance in prematurely ending life.2 Studies show that nurses in a variety of settings receive requests for aid in dying.3 Nurses have an obligation to assess and respond to these requests to relieve suffering while respecting dignity and choices. A request from a terminally ill patient to hasten death represents a clinical, ethical, and legal dilemma for nurses.
Patients can select several legal options to hasten death and avoid suffering. They may discontinue life prolonging treatment before or during its administration or voluntarily stop eating and drinking. Those with intractable pain may use high dose opioids or select terminal sedation to the point of unconsciousness to treat pain even if this may hasten death. All of the above are generally morally and legally accepted. Although some of the above options may cause the nurse moral distress; it is the request for assisted death (AD) that is most controversial.
Oregon, Washington, and Montana are the only states that have legalized AD. As more states pass laws supporting AD, nurses will be faced with choices regarding the provision of information and caring for the patient and family. Nurses need to consider their comfort with the idea that patients may choose to accelerate dying.4
Several professional organizations have position statements regarding hastening death. The American Nurses Association (ANA) states that the nurse is prohibited from participating in assisted suicide and should provide interventions to relieve pain and suffering of the dying patient, even if they may hasten death.5,6 According to the ANA Code of Ethics for Nurses, nurses may not act with the sole intent of ending a patient’s life even though such action may be motivated by compassion, respect for patient autonomy, and quality of life considerations.6 The Oncology Nursing Society (ONS) position statement does 1 not support AD, but recognizes the supportive role of nursing in the dying process.7
Various professional organizations address the importance of symptom management as a response to requests for AD, which is imperative in providing quality end-of-life care. A request for AD to relieve suffering may go beyond pain and symptom management. Data collected in Oregon from those who selected AD listed the top three end-of-life concerns as loss of autonomy, decreased ability to engage in activities that make life enjoyable, and loss of dignity.8 Despite all palliative care initiatives patients may continue to request AD.
- The Hospice and Palliative Nurses Association (HPNA) is committed to respecting the values of nurses and the patients in their care. Some patient’s choices may conflict with the nurse’s moral and ethical values. Both patient’s rights and nurses’ values should be respected.
- The Hospice and Palliative Nurses Association acknowledges that disagreement exists regarding AD, but maintains their position that HPNA does not support legalization of AD. HPNA does recognize the value of the provision of palliative care until death and the nurse’s role in assessing requests for hastening death.
- When a request for hastened death is made, the nurse shares information about health choices that are legal and support the patient and family regardless of the decision that is made. The nurse listens to the patients concerns and motives, addresses needs through aggressive palliative care to include nonjudgmental interdisciplinary assessment of suffering.
- Nurses respond to requests for hastened death by understanding their own moral and ethical values about hastened death. Nurses who have a moral objection to a patient’s treatment choice have an obligation to ensure that health care needs continue to be met and/or that a timely transfer of care occurs.
- Nurses respect not only the choices made by patients, but also their nurse colleagues. Nurses will not subject patients, families, and peers to judgmental comments or actions regarding the decisions to hasten death.
- Nurses practicing in a state where AD is legal will decide whether their own moral and ethical value system does or does not allow them to be involved in providing care to a patient who has made the choice to end his or her life through AD. Nurses are encouraged to follow their state nursing association guidelines regarding AD.
- The conflict between the public’s desire for the hastening death option and the moral, ethical, and legal concerns of professionals will require professional organizations such as HPNA to provide guidance on nursing’s role.
Definition of Terms
Assisted Death. Entails making a means of suicide (e.g., providing pills) available to a patient with knowledge of the patient’s intention. The patient, who is physically capable of suicide, subsequently acts to end his or her own life. Assisted death is distinguished from active euthanasia. In assisted death, someone makes the means of death available, but does not act as the direct agent of death.5
American Nurses Association Position Statement. Registered Nurses’ Role and Responsibilities in Providing Expert Care and Counseling at the End of Life. 2010. Available at: http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues.... Accessed August 1, 2011,
American Association of Hospice and Palliative Medicine Position Statement. Physician-Assisted Death. 2007. Available at: www.aahpm.org/positions/default/suicide.html. Accessed August 4, 2011.
1. Hudson PL, Schofield P, Kelly B, et al. Responding to desire to die statements from patients with advanced disease: recommendations for health professionals. Pall Med. 2006;20:703-710.
2. Volker DL. Oncology nurses experiences with requests for assisted dying from terminally ill patients with cancer. Oncol Nurs Forum. 2001;28:39-49.
3. Ersek M. The continuing challenge of assisted death. J Hosp Palliat Nurs. 2004;6(1):46-59.
4. Lachman V. Physician assisted suicide: compassionate liberation or murder? Med Surg Nur. 2010;19(2):121-125.
5. American Nurses Association. Position Statement: Assisted Suicide. 1994. Available at: www.nursingworld.org/MainMenuCategories/EthicsStandards/EthicsPosition-Statements/prtetsuic14456.html. Accessed August 1, 2011.
6. American Nurses Association. Code of Ethics with Interpretive Statements. 2001. Available at: nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.aspx. Accessed August 1, 2011
7. Oncology Nursing Society Position. Nurses’ responsibility to patients requesting assistance in hastening death. Oncol Nurs Forum. 2010;37(3):249-250.
8. Oregon Health Department. Oregon health authority annual report. 2011. Available at: public.health.oregon.gov/providerpartnerresources/evaluationresearch/deathwithdignityact/documents/yr13-tbl-1.pdf. Accessed August 9, 2011