Imagine for a moment that you are a 40-year-old man diagnosed with an aggressive glioblastoma. You are married with two children. You have been through a surgical resection and a number of radiation treatments. The tumor in your brain is not responding to the treatments. Your speech is declining, your seizures are worsening, and you are losing coordination. Your wife has put her career on hold to stay home to care for you. You see the fear in the eyes of your wife and children as they wait for the next seizure to hit.
Every day, you can feel the burdens of your care weighing on the shoulders of your family. You worry that your kids' memories of you are being replaced with the helpless convalescent you see in the mirror. You are no longer the father, the husband, the businessman you once were. You are tired, and you are suffering. There must be a better way.
Physician-assisted suicide is one of the most controversial issues in medicine and society. In assisted suicide, a physician or other healthcare provider makes a barbiturate prescription available for a terminally ill patient. The patient then uses it to end his or her own life. In all 50 states, we have the right to refuse treatment even though that refusal will ultimately lead to death. But assisted suicide is only legal in three states: Oregon, Washington and Montana.
How It Works
Guidelines exist to direct practitioners who participate in assisted suicide where it is legal.1 Oregon, the first state to pass legislation for such an act, has the following guidelines:
- The patient must make two oral requests of the attending physician, separated by at least 15 days.
- The patient must provide a written request to the attending physician, signed in the presence of two witnesses.
- The attending physician and a consulting physician must confirm the patient's diagnosis and prognosis.
- The attending physician and a consulting physician must determine whether the patient is capable of making and communicating healthcare decisions for himself or herself.
- If either physician believes the patient's judgment is impaired, the patient must be referred for a psychological evaluation.
- The attending physician must inform the patient of feasible alternatives to suicide, including comfort care, hospice care and pain control.
- The attending physician must request, not require, the patient to notify next-of-kin about the prescription request.
NP and PA Guidelines
The American Nurses Association Code for Nurses clearly specifies that nurses should not deliberately terminate the life of any person.2,3 No guidelines specific to nurse practitioners or physician assistants have been published. Involvement in assisted suicide remains a complex, controversial and very personal decision.
Why Assisted Suicide?
Several studies have identified the concerns of terminally ill patients who have requested assisted suicide. A common reason is a sense of lost control - lost control over the time and manner of death, over future events, over body functioning and over self.
A second major concern is loss of dignity. Patients anticipate and fear humiliation, odors and embarrassing behaviors. A third reason is the worry about becoming a burden to others. Patients also fear they will financially and physically wear down the people they love. If the burden becomes too great, they fear being placed in a nursing home, hospital or other facility to die.
A fourth concern is a lost sense of self. Patients fear losing their identity and their personality, and they fear being remembered as frail or ill. Finally, patients fear the actual and anticipated physical symptoms of their illness, including fatigue, weakness, nausea, vomiting and pain.4,5
Alternatives to Suicide
Assisted suicide continues to be a debated issue in law, in churches and in the homes of patients. Every healthcare provider needs to explore and assess his or her own beliefs about the act. Is it morally permissible to aid a patient in taking his or her own life? Does suffering have purpose? Does autonomy include a person's right to die? Every day, healthcare providers are challenged with questions about end-of-life care and assisted suicide. They need to be aware of the laws and the ethics surrounding the issue in order to be fully prepared for such situations.
NPs and PAs should start by investigating the specific reasons why the patient is requesting assisted suicide. Ask questions such as "How can I help?" "What are your questions or fears?" "What is your quality of life right now?" Only with this information can you begin providing appropriate options for a patient-specific plan of care. Patients require education, support and often creativity in meeting end-of-life needs and wishes. Many treatments are available in this last stage of life to alleviate physical, emotional and spiritual suffering.
Physical suffering may be experienced as pain, nausea, vomiting, fatigue and dyspnea. NPs and PAs in hospice and palliative care specialize in controlling these symptoms and effectively relieve physical suffering through pharmacologic and nonpharmacologic interventions. Encourage all terminally ill patients to seek hospice care for specialized management.
Emotional suffering has many causes and treatments. Anxiety can be caused by unrelieved physical symptoms such as pain and hypoxia, again treated with pharmacologic and nonpharmacologic interventions. It can also be caused by fears about dying or by caregiver issues. Through education and support, fears about death can be addressed. Caregiver issues can be managed through the use of inpatient hospice care, home hospice care, home health aides, hospice respite volunteers, or 24-hour private duty care.
Unresolved family issues such as family discord and role changes after the death of the patient can also cause emotional suffering. These issues can be treated through the involvement of hospice social workers and counselors.
Anticipated grief is also a major cause of emotional suffering. Interventions for anticipatory grief include journaling, writing letters to loved ones, making videos or recordings for family members, and aiding in the planning of one's funeral. Bereavement counselors help patients and families understand what to expect and how to manage their feelings through the different stages of grief.
Interventions are also necessary to treat spiritual suffering at the end of life. Spirituality encompasses the patient's religion (if he or she has one) and often a sense of meaning and purpose. Helping patients find their spiritual meaning and purpose in dying can help them transcend the physical and material meaninglessness of death. Other interventions to achieve spiritual healing include human touch, listening, companionship and empathy. Encouraging life review can also help patients recognize their purpose, value and meaning.2 When NPs and PAs are unable to help a patient find spiritual comfort, it is often appropriate to consult the patient's religious authorities. Chaplains, priests, pastors, rabbis and other spiritual counselors are often able to help patients find spiritual peace.
The care of terminally ill patients requires an interdisciplinary holistic approach that encompasses all patient needs and wishes as life comes to a close. NPs and PAs should be armed with a variety of options to help patients meet their needs.
Lisa Siminski is a student in the family nurse practitioner program at DeSales University in Center Valley, Pa., and practices as an RN at St. Luke's Hospice in Bethlehem, Pa.
1. Oregon State Public Health Division. Death with Dignity Act. http://www.oregon.gov/DHS/ph/pas/index.shtml. Accessed Sept. 16, 2010.
2. Bishop JP. Euthanasia, efficiency, and the historical distinction between killing a patient and allowing a patient to die. J Med Ethics. 2006;32(4):220-224.
3. Mathes MM. Assisted suicide and nursing ethics. Medsurg Nursing. 2004;13(4):261-264.
4. Chapple A, et al. What people close to death say about euthanasia and assisted suicide: a qualitative study. J Med Ethics. 2006;32(12):706-710.
5. Pearlman RA, et al. Motivations for physician-assisted suicide. J Gen Intern Med. 2005;20(3):234-239.