Correspondence
The Role of Critical Care Nurses in Euthanasia and Assisted Suicide
N Engl J Med 1996; 335:971-974September 26, 1996
- Article
To the Editor:
As a clinical nurse specialist and cochairperson of the Hospital of the University of Pennsylvania's ethics committee, I am compelled to respond to Asch's study (May 23 issue)1 by stating that this research has unnecessarily induced public distrust and fear of hospital care. In newspapers across the country, this study generated dramatic headlines, including “One in five nurses help patients die” (USA Today) and “In Penn Survey, one in five nurses admits to mercy-killing” (Philadelphia Daily News). I know of several instances during the week following the publication of the study in which families asked nurses if their loved ones were safe in the hospital.
The conclusion that one in five nurses have helped patients die cannot be supported, simply because the survey questions were unclear. Although the questions included the phrase “intent of causing . . . a patient's death,” other terms, such as “an overdose of opiates,” were vague and not defined. After the publication of the study, I participated in a discussion in which the survey questions were presented to 15 experienced critical care nurses, all of whom said they could not respond definitively because the questions were ambiguous. For example, several participants said that although death may be hastened by a given treatment, death is not the primary goal of the treatment. Additional discussion centered on the fact that terminal patients who are suffering often require higher-than-standard doses of morphine, and a higher dose of morphine is not an overdose but simply one that is titrated to achieve the needed effect.
Although Asch has stated that “some are disappointed with the study's findings” (Philadelphia Inquirer, June 15, 1996), the real disappointment lies in the message that was conveyed to the public — that critical care units can be unsafe places. Health care professionals now must work to restore the public's faith.
This study has value in that it will prompt open and honest discussion among patients, families, nurses, physicians, and other health care professionals about end-of-life decisions. If disagreement exists, the people making these decisions should rely on the support of a hospital ethics committee whose members' expertise lies in facilitating communication and conflict resolution. Such collaboration results in better patient care, improved outcomes, and patients and families who are more satisfied, more trusting, and less litigious.
1 ReferencesPatricia A. Dunn, M.S.N., R.N.C.
Hospital of the University of Pennsylvania, Philadelphia, PA 19104-42281
Asch DA . The role of critical care nurses in euthanasia and assisted suicide. N Engl J Med 1996;334:1374-1379
Full Text | Web of Science | Medline
To the Editor:
Dr. Asch identified an important area of concern for all health care professionals and society at large, but his article contains a number of methodologic flaws that interfere with the interpretation of the study's results. The sample may not be an accurate reflection of critical care nurses. The sample was drawn from subscribers to a clinical magazine, Nursing, whose intended audience is medical and surgical nurses and which therefore may not represent the critical care nursing specialty. Of the 1600 respondents, half received three mailings over a period of three months, and the surveys were not coded. Thus, there was no control over the number of surveys individual respondents may have submitted. There was no description of characteristics commonly used to describe critical care nurses (e.g., educational level and certification) and practice sites (e.g., the total number of beds and the number of beds in the intensive care unit). Therefore, the generalizability of the findings cannot be evaluated. Finally, insufficient information was provided about the number of items in the survey, its development, or its psychometric properties.
Dr. Asch reports that the survey provided definitions of “euthanasia” and “assisted suicide” but that none of the individual survey items contained these terms. Nevertheless, survey findings use these terms. Only 19 percent of the nurses “answering yes to the question about participation in euthanasia or assisted suicide provided descriptions of actions or intent sufficient to meet the definition used in the question.” It is unclear why the remaining 81 percent of nurses who gave responses not clearly compatible with the researcher's definitions were still counted as having participated in euthanasia or assisted suicide.
In defining the terms, one of the examples of an act with the intent of causing or hastening a patient's death was “increasing dose or frequency of a morphine intravenous drip in a patient already unconscious.” This example implies that the intent of all situations in which the rate of a morphine infusion is increased when the patient is unconscious is to cause or hasten the patient's death. In clinical practice, patients with an altered level of consciousness may be given increased doses of morphine to minimize any assessed discomfort associated with hypoxemia or pain produced by coexisting pathophysiologic processes. The intent of these actions is to ease breathing or relieve pain and suffering and not to hasten the patient's death.
Decisions about the delivery of care at the end of life most frequently include the patient, the family, nurses, physicians, and clergy. Of the nurses who reported having participated in at least one case of euthanasia or assisted suicide (16 percent of the study population), 10 percent had participated at the “request of the attending physician” and 3 percent at the “request of a physician not the attending physician.” It therefore is possible that the large majority of positive responses reflected the multidisciplinary process generally surrounding end-of-life care rather than independent actions by the nurses.
Despite its considerable flaws, the results of this survey confirm the importance of open discussions about the care desired by patients and families, especially at the end of life. The results of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) suggest that patients vary widely in their willingness to tolerate adverse outcomes and in their preferences with regard to extending life.1 Asch's survey apparently did not include requests for information about the availability of resources for resolving ethical conflicts, such as multidisciplinary ethics committees. Such committees can be an important mechanism to support bedside nurses, physicians, patients, and families when they are making decisions at the end of life. Improved communication among all parties might have prevented any actions to hasten patients' deaths outside of procedures for the withdrawal of life-sustaining treatment.
1 ReferencesNancy L. Szaflarski, Ph.D., R.N.
John M. Clochesy, Ph.D., R.N.
Nursing Section, Society of Critical Care Medicine, Anaheim, CA 92808-22141
Tsevat J ,Cook EF ,Green ML , et al. Health values of the seriously ill. Ann Intern Med 1995;122:514-520
Web of Science | Medline
To the Editor:
Both Asch's survey of critical care nurses and their role in euthanasia and assisted suicide and Scanlon's comments in the accompanying editorial (May 23 issue)1 illustrate the difficulty of clearly defining “assisted suicide” as it relates to nurses.
Unlike physicians who can prescribe a lethal dose of medications (a defining characteristic of “physician-assisted” suicide), nurses are not licensed to prescribe medications. Yet nurses are intimately involved in the care of patients with end-stage diseases and may see them more frequently than their physicians do. Such patients may ask nurses to assist them in committing suicide in a wide variety of ways, such as by providing information about how to commit suicide, remaining with patients who have intentionally taken medication overdoses while they die, or administering an overdose of medications with the intent of causing death. Although it is debatable whether the first two actions constitute “assisting” in a patient's suicide, they are clearly in a legal and ethical gray area.
Using an anonymous, self-administered questionnaire, we recently surveyed by mail 428 nurses working at facilities serving patients with AIDS in the San Francisco Bay Area (including inpatient units, outpatient clinics, hospice and home care agencies, clinical-research programs, and long-term-care facilities) about their professional and personal experiences with AIDS, their beliefs and attitudes toward assisted suicide, and their participation in assisted suicide.2 We defined assisted suicide as “active involvement by the nurse in a patient's planning and implementing his/her own suicide.”
We received 215 responses, for a response rate of 50 percent. Respondents reported working with a median of 150 patients with AIDS. Three nurses who reported no experience working with AIDS patients were excluded. Fifteen percent of respondents reported ever assisting in the suicide of a patient with AIDS (Table 1Table 1
Participation of Nurses in Assisted Suicides of Patients with AIDS.), a figure similar to the 16 percent in Asch's study. When asked to consider a hypothetical patient — mentally competent, severely ill, and facing imminent death — who requests assistance in committing suicide, 73 percent of the respondents reported that they would answer the patient's questions about lethal doses of medications, 67 percent said they would remain at the bedside after the patient had intentionally taken a lethal dose, and 14 percent reported that they would administer a lethal dose.It is clear from Asch's data and our own that some nurses are participating in assisted suicide and that many more are sympathetic to the idea. Recent rulings by the Second and Ninth Circuit U.S. Courts of Appeals support the right of terminally ill patients to hasten their deaths with drugs prescribed by their physicians. Should these decisions become law, what legal protections will be provided to nurses who are asked by patients to assist them in committing suicide? Open discussion of the complex moral, ethical, and legal dimensions of this phenomenon, including the implications for all health care professionals involved in the care of terminally ill patients, is essential.
2 ReferencesRoslyn J. Leiser, R.N.
Thomas F. Mitchell, M.P.H.
Judith A. Hahn, M.A.
Donald I. Abrams, M.D.
University of California, San Francisco, San Francisco, CA 941431
Scanlon C . Euthanasia and nursing practice -- right question, wrong answer. N Engl J Med 1996;334:1401-1402
Full Text | Web of Science | Medline2
Leiser R, Mitchell T, Hahn J, et al. Nurses' attitudes toward assisted suicide in AIDS. Presented at the 11th International Conference on AIDS, Vancouver, July 7–12, 1996. abstract.
To the Editor:
The article by David Asch suggests that one in five of the nurses surveyed participated in active euthanasia. These nurses suggested that they were trapped in desperate situations, caring for suffering patients unlikely to survive the endless application of life support by unrealistic physicians.
Immediate attention must focus on end-of-life care to ensure that critical care nurses are never trapped in situations that lead them to consider euthanasia. Withdrawal of life support, with control of pain and suffering, in the face of a hopeless prognosis is most appropriately done with the consent of the patient or family by the nurse-and-physician team in the intensive care unit. Intensive care nurses secretly euthanizing patients to end their suffering is unacceptable. Many aspects of the survey are questionable because of respondents' confusion over the differences between the appropriate withdrawal of life support and active euthanasia.
Critical care nurses are patients' advocates, who focus on their comfort and recovery. By virtue of their continuous presence at the bedside, these nurses understand a truth that eludes many: that despite our best efforts, not all patients will recover, and for them, pain and suffering — and not death — are the enemy.
We must change the way we care for these patients. We must withdraw life support when recovery is impossible. We must relieve pain and suffering. And, we must change the way care is delivered. Compassionate, efficient care, provided by multidisciplinary teams of fellowship-trained intensivists, highly educated critical care nurses, and qualified allied health professionals — experienced in managing pain and suffering — must prevail.
Recent events — the publication of the SUPPORT study, the decisions of the Second and Ninth Circuit Courts, and the public focus on end-of-life care — call us to action. To this end, the Society of Critical Care Medicine will soon convene “Critical Caring: A Consensus Conference on Care at the End of Life” in Washington, D.C.
John W. Hoyt, M.D.
Maurene A. Harvey, R.N., M.P.H.
Ginger S. Wlody, R.N., Ed.D.
Society of Critical Care Medicine, Anaheim, CA 92808-2259Author/Editor Response
The authors reply:
To the Editor: Several letters express concern about the methods used in this study. Some of the issues raised echo those in a press statement issued jointly by the American Nurses Association and the American Association of Critical-Care Nurses1 as well as in the editorial accompanying the paper. The most pervasive criticism is that a key question in the survey about euthanasia was vague or too broad for its goals.
The question was, “While a critical care nurse, have you ever administered a medicine to a patient or performed some other act with the intent of causing or hastening that patient's death — other than the withdrawal of life-sustaining treatment?” Although this question seems clear, the circumstances surrounding these activities often are not, as the responses elicited reveal. The activities nurses described differ in many dimensions that may be relevant to their interpretation: how open or deceptive the practice was, whether the practice was consistent with physicians' orders or the patient's preferences, how the activity was performed, and the clinical circumstances of the patient. That these activities can differ in many dimensions is not a flaw of the study but rather an empirical finding worthy of further investigation in other studies designed to focus on the various dimensions.
This complexity is compounded because the term “euthanasia” is loaded. Those who believe that the term can refer properly only to activities that are immoral may also feel that it cannot apply to all the activities reported by the nurses. If there is a continuum of moral appropriateness represented here, it is not clear where the moral divide lies, whether there is a single divide, or whether that divide is shifting over time. The range of activities described by the nurses who participated in this study may reveal the inadequacy of the term “euthanasia” and the many professional and legal policies built on it.
Some have wondered also whether the numbers reported in the study overstate the true proportion of nurses who have intentionally hastened death. One might also wonder whether the numbers are underestimates, because those who have engaged in these activities might be reluctant to report them. It is interesting that Ms. Leiser and her colleagues report similar figures from their study of nurses caring for patients with AIDS. Even so, the important finding of the study is not what the percentage of nurses is but that actions intended to hasten death occur to a measurable degree.
Regardless of the prevalence of these activities, the issues they raise are pervasive and troubling. The results of this study are a symptom of a problem rather than a problem in themselves. Perhaps the study's central finding is that many nurses find the environment of the intensive care unit unresponsive to some patients' suffering. Many nurses revealed how motivated they are to respond to that suffering but also that they confront a variety of barriers that can make that goal difficult to achieve. The challenge highlighted by this study is to overcome these barriers.
1 ReferencesDavid A. Asch, M.D.
University of Pennsylvania School of Medicine, Philadelphia, PA 19104Author/Editor Response
I would like to thank Leiser and her colleagues for providing information about their study and for continuing to raise questions worthy of exploration. Although it is not possible to evaluate the validity of this study adequately without additional information and access to the survey instrument, initial assessment raises issues similar to those raised by the Asch study — that is, the difficulty of defining terms and delineating practices that may constitute assisted suicide and euthanasia. The definition of assisted suicide used in the study by Leiser et al. is different from that used in the Asch study, which makes comparisons of their findings problematic. What is clear from both studies is the difficulty of conducting empirical research on highly complex, controversial, and frequently misunderstood subjects such as assisted suicide and euthanasia.
The true merit of the studies by both Asch and Leiser et al. is that they force health professionals and others to discuss these issues, examine the realities of clinical care, and evaluate the boundaries of professional practice. This level of discernment is essential if nurses and other health professionals are to act in a reasoned, responsible, and ethically sound manner. Until there is further clarification and acceptance of the distinctions between justified actions that may lead to death (e.g., increasing the dosage of opiates to alleviate pain) and those that cannot be justified (e.g., injecting a lethal dose of potassium), patients will suffer needlessly because health professionals will continue to be confused about appropriate end-of-life care.
In response to the Asch article, the nursing community expressed concern over the methodologic limitations of his research and the likelihood that it might cause public fear, erode the trust of patients and families who depend on nurses, and undermine the strides made in palliative care. The nursing profession has long recognized the inadequacy of care rendered to the critically ill and dying and has vigilantly advocated the provision of humane and dignified end-of-life care. Nurses will continue to struggle with the tension between being committed to the nonabandonment and compassionate care of patients at the end of life and refraining from participation in assisted suicide and euthanasia. Tragically, assisted suicide has become the contemporary moral cause and is being championed as the only way to escape the anticipated degradation of dying; the true moral cause should be to eradicate the inadequacies and despair of the last stages of life and fulfill the obligation to give competent, compassionate, and committed care to the dying.
Colleen Scanlon, R.N., J.D.
American Nurses Association Center for Ethics and Human Rights, Washington, DC 20024-2571- Citing Articles (1)
Citing Articles
1
Kristie E. Jackson, William L. Jackson. (2009) Flawed assumptions surround concept of physician-assisted death. Critical Care Medicine 37:8, 2494-2495
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