AUSTIN, Texas-Although the nursing profession supports patient empowerment and self-determination in health care decision-making, patient requests for assisted dying raise difficult issues. A study reported at the Oncology Nursing Society’s 26th Annual Conference explored the symptom management strategies that some nurses use to either counter or preempt patient requests for help in dying.
AUSTIN, TexasAlthough the nursing profession supports patient empowerment and self-determination in health care decision-making, patient requests for assisted dying raise difficult issues. A study reported at the Oncology Nursing Society’s 26th Annual Conference explored the symptom management strategies that some nurses use to either counter or preempt patient requests for help in dying.
Deborah L. Volker, RN, PhD, assistant professor, University of Texas School of Nursing, Austin, reported results from a secondary analysis of her larger study of how nurses receive and respond to patient requests for assistance in dying.
The original study group was derived from a randomized, sequential mailing of questionnaires to 1,600 ONS members. The questionnaire used a broad definition of assisted dying, which included not only assisted suicide and active euthanasia but also nurse-provided advice and teaching related to assisted dying.
Among the 76 oncology nurses who responded to the questionnaire, 40 had received patient requests for assisted dying. The remaining 36 had not received such a request but chose to share their experiences with end-of-life care.
The study group was representative of the Oncology Nursing Society as a whole, Dr. Volker said, consisting primarily of white female nurses who were mostly Christian in their religious orientation. The mean age was 46 (range, 24 to 81), and the mean years of nursing experience was 22, 15 of which were in oncology nursing.
This secondary analysis focused on the types of symptom management strategies oncology nurses use in end-of-life care. The final sample for the secondary analysis was 12 nurses who had denied requests for assisted dying and had countered with palliative care and 24 nurses who had not received a request but chose to share their palliative care practices and experiences.
The nurses’ personal stories revealed a variety of symptom management strategies. Nurses who had received and denied requests for assisted dying described a variety of physical, emotional, and spiritual strategies. Dr. Volker read excerpts from some of these nurses’ responses.
"One nurse said, ‘I refused to give extra doses of morphine for that purposeof ending lifebut was readily available to provide medication to control pain and anxiety. And I did adjust the IV dose based on clinical judgment, not to hasten my patient’s death.’"
‘Can’t You Do Something?’
Similarly, Dr. Volker said, a hospice nurse shared the story of a patient who asked her, "Can’t you do something to end this pain and suffering now? Something that will end my life." She responded that she could not fulfill that request but said, "My presence and work will be to eliminate as much pain as possible and to keep you comfortable at home. Pain control starts today, and before I leave, you will be in less pain."
The other group of respondents, those who had not received requests for assisted dying, relayed their experiences of providing comfort care, managing medications, and serving as teachers or advocates for their patients. Some excerpts:
"In all my years in end-of-life care, now practicing as a palliative care nurse practitioner, I have never had one of my patients request to die. I believe that because I have worked with a very strong interdisciplinary team, have learned to treat depression early on, and know how to properly manage pain symptoms, my patients die healthy deaths."
Another nurse wrote, "Chasing symptoms with polypharmacy is something I frequently see in many hospice programs. If I’ve come to a juncture in my patient’s care that dictates sedation for unrelieved symptoms after sequential trials of meds, I will offer terminal sedation for patients in pain should the need arise . . ."
In a final excerpt, a nurse said, "I have rearranged pain medication schedules, defined as terminal to patients, and discussed the merits of hospice on countless occasions. I have discussed the quality of sleeping, eating, moving, pursuing pleasurable activities, and general living to multitudes of individuals in order for them to make an informed choice between life and death."
Dr. Volker commented, "The encouraging finding here is that the interventions both groups of nurses described were very much consistent with current recommendations to implement comfort care strategies in response to requests for assisted dying."
The American Nurses Association (ANA) cites this as the appropriate response, as does ONS, and the Oregon Nurses Association, "the colleagues we look to for setting the tone for responding to these types of requests," she said.
However, she said, there is a concern that comprehensive, competent palliative care services are still lacking. "The one story about the hospice nurse who said to her patient ‘Comfort care and pain management will start now’ disturbed me because my first question was ‘Where were the nurses and physicians before this patient reached hospice and had to cry out to his nurse?’"
Dr. Volker raised the ethical question of whether the denials of a patient’s request for assistance in dying were consistent with the advocacy role that nurses play with their patients.
"Was this a conscious decision to override the patient’s assertion of his right to self-determination or autonomy?" she asked. "The ANA Code of Ethics for Nurses is being revised as we speak and, specifically, those working on that initiative say that they are going to strengthen the language about nurses’ roles in advocacy. So it will be interesting to see how that plays out."