Guidelines for the Role of the Registered Nurse and Advanced Practice Registered Nurse When Hastened Death is Requested
This position statement was endorsed by the ONS Board in September 2019 and was republished with permission from the Hospice and Palliative Nurses Association (HPNA).
People living with advanced illnesses who want to hasten death or avoid prolongation of dying have various options available to them. The Patient Self Determination Act1 allows patients to refuse or stop life-sustaining therapies (e.g., ventilator support, cardiac support devices, feeding tubes, nutrition and hydration, etc.),2 and in states where physician-assisted death/physician-assisted suicide (PAD/PAS) is legal, this as an option as well. It is therefore necessary that palliative and hospice registered nurses (RNs) and advanced practice registered nurses (APRNs) understand the issues related to PAD/PAS. The issues germane to clinical practice include: professional statements, state statutes, organizational policies, patient-centered care, and resource utilization.
The Hospice and Palliative Nurses Association (HPNA) position statement on PAD/PAS states that HPNA does not recognize PAD/PAS as part of palliative care but does emphasize that all patients are entitled to expert and compassionate palliative care.3 Given that PAD/PAS is legally sanctioned in many states, with legislation in additional states anticipated, guidelines to assist palliative and hospice nurses on how to respond when hastened death is requested are necessary.
The essence of nursing is care for patients across the life cycle. Palliative and hospice nurses focus on the promotion of quality of life to enable patients to live as fully as possible, on their terms, from diagnosis to death. Because the trajectory of dying has changed and people are living longer with progressive debilitating diseases, palliative and hospice nurses care for patients in a variety of settings including acute care, critical care, clinic, home care, long-term care, and hospice care settings.
Caring for patients with progressive debilitating diseases can be challenging especially in the presence of advanced technology when life can be prolonged for extended periods of time and the dying process protracted. In addition, with 2 overall advances in disease-directed treatment and preventative healthcare, sanitation and nutrition, many people are living longer lives.
Through quality palliative nursing care, most patients experience a peaceful death. However, a person with serious illness may find it difficult to accept a quality of life they deem unacceptable. They may experience existential distress, fear of loss of control, and fear of burdening their family, among other things. This may lead to the desire to hasten their death, often in the form of a request for PAD/PAS to enable a death that comes at a time of their choosing.
Many such patients still require and expect expert palliative and hospice care. It is essential that palliative and hospice nurses are prepared to deliver care to all patients, including those who have requested a hastened death.
To effectively and compassionately respond to the palliative care needs of patients who may hasten death, it is important for RNs and APRNs to proactively consider the issues related to such a request. This includes the Code of Ethics for Nurses with Interpretive Statements and the nurse’s personal core values. By understanding these aspects of caring for a patient who requests a hastened death, nurses can create a patient-centered plan of care.
Individual palliative and hospice nurse responsibilities:
Nursing process for patients requesting a hastened death:
Responding to Requests for Hastening Death12
Autonomy: A multidimensional ethical concept. It is the right of a capable person to decide their own course of action based on personal values and goals of life. Self-determination is a legal right.13,14
Dignity or respect for person: A fundamental ethical principle. Dignity is the quality and state of being honored or valued. Respecting the body, values, beliefs, goals, privacy, actions, and priorities of an autonomous adult preserves their dignity. This is a broader concept than autonomy.13-15
Fidelity: The ethical imperative to keep promises. For healthcare providers, fidelity includes the promise not to abandon the patient.13
Forgoing life-sustaining treatment: To do without a medical intervention that would be expected to extend the patient’s life. Forgoing includes withholding (not initiating) and withdrawing (stopping).16
Life-sustaining therapies: “Any medical intervention, technology, procedure, or medication that forestalls the moment of death, whether or not the treatment affects the underlying life-threatening diseases or biological processes. Examples include mechanical ventilation, dialysis, CPR, antibiotics, transfusions, nutrition, and hydration.”16
Palliative sedation: “When terminally ill, conscious patients experience intolerable symptoms that cannot be relieved by expert palliative care, palliative sedation involves administering sedatives and nonopioid medications to relieve suffering in doses that may induce unconsciousness, but not death.”17(pp583)
Physician-assisted death (PAD)/Physician-assisted suicide (PAS): The practice of a physician providing a terminally ill patient, who has decision-making capacity, the means to take their own life through the provision of a prescription for a lethal dose of medication.18
Refractory symptom: A symptom that cannot be adequately controlled in a tolerable time frame or at a tolerable level despite aggressive use of usual 5 therapies and seems unlikely to be adequately controlled by further invasive or noninvasive therapies without excessive or intolerable acute or chronic side effects/complications.19
1. Patient Self-Determination Act of 1990, HR 4449, 101st Cong, 2nd Sess (1990).
2. McCormick AJ. Self-determination, the right to die, and culture: a literature review. Soc Work. 2011;56(2):119-128.
3. Hospice and Palliative Nurses Association. Physician-Assisted Death/Physician-Assisted Suicide. Pittsburgh, PA. 2013; http://advancingexpertcare.org/wp-content/uploads/2017/07/PhysicianAssi…. Accessed July 13, 2017.
4. American Nurses Association. Nursing Scope and Standards of Practice. 3rd ed. Silver Spring, MD: American Nurses Association; 2015.
5. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association; 2015.
6. American Nurses Association. Euthanasia, Assisted Suicide, and Aid in Dying. Silver Spring, MD: American Nurses Association. 2013; http://www.nursingworld.org/euthanasiaanddying. Updated April 24, 2013. Accessed July 13, 2017.
7. American Nurses Association. Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions. Silver Spring, MD: American Nurses Association. 2012; www.nursingworld.org/dnrposition. Updated March 12, 2012. Accessed July 13, 2017.
8. American Nurses Association. Registered Nurses’ Roles and Responsibilities in Providing Expert Care and Counseling at the End of Life. Silver Spring, MD: American Nurses Association. 2010; www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positionsand-Re…. Updated June 14, 2010. Accessed July 13, 2017.
9. American Nurses Association, Hospice and Palliative Nurses Association. Palliative Nursing: Scope and Standards of Practice. Silver Spring, MD: American Nurses Association; 2014.
10. Dahlin C, ed. Competencies for the Hospice and Palliative Advanced Practice Nurse. 2nd edition. Pittsburgh, PA: Hospice and Palliative Nurses Association; 2014.
11. Sutermaster DJ, Dahlin C. Competencies for the Hospice and Palliative Registered Nurse. 3rd edition. Pittsburgh, PA: Hospice and Palliative Nurses Association; 2015.
12. Orentlicher D, Pope TM, Rich BA. Clinical criteria for physician aid in dying. J Palliat Med. 2016;19(3):259-262. doi:10.1089/jpm.2015.0092.
13. Beauchamp TL, Childress JF. Principles of Biomedical Ethics 7th ed. New York: Oxford University Press; 2012.
14. Dalinis PM. Informed consent and decisional capacity. Journal of Hospice and Palliative Nursing. 2005;7(1):52-57. 073018 6
15. Elsayem A, Curry LE, Boohene J, et al. Use of palliative sedation for intractable symptoms in the palliative care unit of a comprehensive cancer center. Support Care Cancer. 2009;17(1):53-59. doi:10.1007/s00520-008-0459-4.
16. Policy on Forgoing Life-Sustaining or Death-Prolonging Therapy. Cleveland Clinic Web site. https://www.clevelandclinic.org/bioethics/policies/policyonlifesustaini… code.html. Accessed March 20, 2018.
17. McPhee SJ, Winker MA, Rabow MW, Pantilat SZ, Markowitz AJ. Care at the Close of Life: Evidence and Experience. New York, NY: The McGraw Hill Companies; 2011.
18. Medical Definition of Physician-Assisted Suicide. Medicine Net Web site. https://www.medicinenet.com/script/main/art.asp?articlekey=32841. Accessed March 20, 2018. 19. Arnstein PR, Robinson EM. Is palliative sedation right for your patient? Nursing. 2011;41(8):50-54. doi:10.1097/01.NURSE.0000399637.52835.d8.
This position statement reflects the bioethics standards or best available clinical evidence at the time of writing or revisions. This position statement is based on evidence that reflects patients with advanced illnesses and may not be applicable in all palliative circumstances.
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