Human Exceptionalism

Urging Hospice Nurses to Act Beyond Their Authority at End of Life

This commentary by a nurse Ph.D published in Nursing Center is very disturbing. Judith Schwartz suggests that hospice nurses inform patients about methods to legally end their lives where assisted suicide is illegal. Schwartz discusses the patient with intractable symptoms who seeks hastened death. From the column:

In 1994 the American Nurses Association (ANA) confirmed that nurses shouldn’t “[make] the means of suicide ([such as] providing pills or a weapon) available to a patient with knowledge of the patient’s intention.” But the ANA did not include taking appropriate palliative measures in its definition of assisted suicide.

Nurses who care for terminally ill patients must be encouraged to inform patients who ask about all legally and ethically sound palliative options, including those that might hasten dying: forgoing life-prolonging interventions, refusing food and fluids, and receiving high doses of opioids or palliative sedation that causes unconsciousness. When terminally ill, suffering patients use such legal means to hasten their dying, they aren’t committing suicide. Nurses who provide information on or support such choices aren’t assisting in suicide.

But nurses still must intervene to prevent irrational suicidal acts made by patients suffering from mental illness (particularly depression) or impulsive acts of self-destructive behavior that may be driven by despair, guilt, or hopelessness. Patients suffering from acute or chronic mental illness that interferes with their ability to make informed decisions and who aren’t terminally ill but want to die are not the same as competent patients suffering from a terminal illness who seek to hasten dying. Both groups of patients are suffering and need help: different kinds of help.

Often, good palliative or hospice care alleviates the suffering of the dying. Nonetheless, a small but significant proportion of dying patients suffer intolerably. Although most don’t seek a hastened death, some will ask about it. And when they do, nurses experience a great moral conflict: they want to help their patients die well, yet they don’t want responsibility for helping them to die.

Patients who are dying have no control over the inevitability of their death. When they suffer intractable symptoms, they should receive complete end-of-life support from nurses. It’s the least we can provide.

Absolutely not! First, to use the now cliche` term, deciding whether a patient has a mental illness and hence, is asking for “irrational” suicide is way above a nurse’s pay grade. That is a job for a mental health professional. In that circumstance, it is the explicit job of a hospice nurse to tell the multidisciplinary team about the desire to hasten death so that the properly trained person can help the patient.

Second, patients are certainly entitled to refuse life-sustaining treatment. Sometimes palliative sedation is an appropriate measure. But discussing these options, and making decisions about which way to go, is a job for the doctor and patient, not patient and nurse.

Patients can develop very intense emotional connections to their nurses. Realizing that, it is up to nurses to compassionately care for their patients but beware unduly influencing them. More to the point, it is not their job to diagnose physical or mental health issues or to intervene with the patient and help (persuade) them to pursue certain medical options.

Following Schwartz’s advice would be very bad for nurses and patients.