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Physician-assisted suicide is described by Dyer, White, and Rada as ”prescribing life ending drugs for terminally ill, mentally competent adults to administer themselves” (as cited in BMJ, 2015). Who are we to choose how someone should handle the end of their life? “The suffering of dying patients may be great and is caused by somatic symptoms, such as pain and nausea; psychological conditions, such as depression and anxiety; interpersonal suffering due to dependency or unresolved conflict; or existential suffering based in hopelessness, indignity, or the belief that one’s life has ended in a biographical sense but has not yet ended biologically. For some patients; a sense of control over the manner and timing of death brings comfort” (Sulmasy & Mueller, 2017).

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Due to the limitations that nurse’s face, there isn’t too much they CAN do regarding physician-assisted suicide. Their greatest role when faced with this ethical dilemma is to advocate for their patient. Additionally, it is within a nurse’s scope of practice to help “terminally ill patients prepare for death and to ‘minimize unwarranted or unwanted treatment and patient suffering’ by counseling them with respect to decisions” (ASRN, 2010). However, as previously mentioned, nurses are forbidden under their Code of Ethics to intervene with the intent of ending a patient’s life, regardless of the patient’s requests.

While some nurses may not agree with physician-assisted suicide, the nurses that do can help implement change by continuing to advocate for their patients’ autonomy.

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ANALYSIS: Why the nurse’s involvement is important

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ANALYSIS: Why the nurse’s involvement is important

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The nurse’s presence is at the bedside; they are (arguably) more directly involved in the patients’ care than any other member of the interdisciplinary team. The International Council of Nursing (as cited in Monteverde, 2017) states that “Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering.” With that in mind, it is in the nurse’s scope of practice to alleviate the suffering that can be associated with terminal illness. Additionally, their involvement at the bedside would allow the process of physician-assisted suicide to be even more humane; nurses are often present during a patient’s final moments and are able to provide comfort, support, and love to the patient and the families.

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What is the problem?
While some view physician-assisted suicide (PAS) as providing a painless and peaceful death to terminally ill patients, others “believe the consequence of any form of suicide will ultimately result in irreparable legal and ethical ramifications” (Llamas, 2018).

How?
Physician-assisted suicide, as defined by the American Medical Association (2019), “occurs when a physician facilitates a pateint’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide).”

Where?
PAS is currently only legal in seven US states and the District of Columbia. According to CNN (2019), it is mandated by law in Colorado, Disctrict of Columbia, Hawaii, Oregon, Vermont, and Washington; it is mandated by court ruling in Montana and California. The controversy is still nationwide and it remains illegal in forty-three US states.

Who is affected?
The controversy and legalities associated with physician-assisted suicide effect any terminally ill patient that would prefer to end their life in this manner and are unable to. As previously mentioned, it is illegal in 43 states, and in the states/districts where PAS is legal, the “individuals must have a terminal illness as well as a prognosis of six months or less to live” (CNN, 2019).

When?
When given a terminal diagnosis, a patient may want to begin discussing their options - one of those being PAS. Many patients would rather not spend months or years suffering and in pain. Additionally, they would not like their significant other, children, family, and friends to watch them wither away or progress toward death.

Why?
There are many reasons that people desire PAS. When terminally ill, some patients are in excruciating and unbearable pain. For others, they are experiencing a loss of control and although they can’t control their illness, they want to be in control of how they die. Other factors include decreasing quality of life and loss of autonomy. Patients can be experiencing one, a variety, or all of these effects of terminal illness.

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ANALYSIS: What are the challenges or barriers for nurse involvement? 

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ANALYSIS: What are the challenges or barriers for nurse involvement? 

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Nurses are not very involved in physician-assisted suicide; not necessarily because they don’t WANT to be, but because the position of their governing body does not allow it. This governing body, The American Nurses Association (ANA), represents the registered nurses in the United States and exists to foster high standards of practice, promote a work environment that is both safe and ethical, bolster the overall well-being of nurses, and advocate on issues that affect nurses and the public (ANA, n.d.a). The official statement of the American Nurses Association as it relates to this issue conveys that the ANA “prohibits nurses’ participation in assisted suicide and euthanasia because these acts are in direct violation of Code of Ethics for Nurses with Interpretive Statements, the ethical traditions and goals of the profession, and its covenant with society” (ANA, 2013). Conclusively, the ANA (2013) states that while they recognize this is an ongoing debate, they strictly prohibit participation of the nurse.

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Argument in favor of PAS
The argument in favor of PAS is centered “around respect for autonomy, compassion for unremitting suffering, support of personal liberty vs. the state’s interest in preserving life, and justice” (Lachman, 2015). While there is much negative connotation that surrounds the process of assisted suicide, arguments for convey that competent terminal individuals should be given the option of assisted suicide to cease suffering and pain, eliminate the financial burden created by receiving extended care, and preserving their autonomy and right to deciding their own fate (Lone Star College, 2019).

Argument against PAS
While many arguments against physician-assisted suicide are rooted in religious beliefs, there are also other notable viewpoints. Sulmasy, Travaline, Mitchell & Ely (2016) present four non-religious arguments; suicide devalues human life, there are alternative ways to alleviate pain through palliative care and modern therapeutics, physician-assisted suicide violates and undermines the trust that patients have for physicians, and the limits on euthanasia gradually erode.

Overall Summary
When discussing physician-assisted suicide, the argument lies in the fine line that separates killing and relief from dying. In an article from Z. Zylicz (as cited in USCCB, 2011), a Netherlands hospice physician recounted a time that there was a terminally ill patient with a bowel obstruction. The physician had to teach another physician how to relieve the obstruction; the other physician replied that he would normally solve this sort of issue with euthanasia. “It illustrates how euthanasia becomes a substitute for learning how to relieve the suffering of dying patients” (USCCB, 2011). It is scenarios like this that make it understandably difficult to argue in favor of physician-assisted suicide. Unfortunately, for the patients that would benefit from the option and who intend to exercise it appropriately, they are forced to turn to alternative methods of ending their own life. One commonly practiced alternative is the voluntary stopping of eating and drinking (VSED). Valente conveys that “When a person stops eating and drinking, death occurs in 1-3 weeks” (as cited in Lachman, 2015).

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Two curricular concepts:
Advocacy
Advocacy in nursing “has been defined as being a patient representative, defending the patient’s rights and universal rights, protecting the interests of the patient, contributing to decision-making and supporting the patient’s decisions, ethical-centered skills for the ‘professional self’, and ‘being a voice for the vulnerable’” (Davoodvand, Abbaszadeh & Ahmadi, 2016).

Interdisciplinary collaboration
The Canadian Association of Occupation Therapists have defined interdisciplinary collaboration as “the positive interaction of 2 or more health professionals, who bring their unique skills and knowledge to assist patients/clients and families with their health decisions” (as cited in CPJ, 2007).

Leadership role
These curricular concepts attained during my nursing education are crucial to holistic patient care. When facing a serious disease or terminal illness, patients are “dealing with fear, uncertainty and disruptions in every key aspect of their lives” (Buzaglo, 2016). It is imperative that we help them find their voice; we must advocate on behalf of our patients, but we must also teach them how to advocate for themselves! Joanne Buzaglo (2016) conveys that “While most patients report receiving information about their treatment options, less than half report being knowledgeable . . . and a significant proportion reported not having enough knowledge or support to fully engage in treatment decisions.” Teaching our patients to advocate for themselves will ensure that when facing a terminal illness, the patients that opt for PAS are fully educated on ALL options available to them, as opposed to making a rash decision. In the leadership role, the ability to collaborate successfully with other members of the interdisciplinary team is also monumental to the care provided. “It is recognized that teamwork and shared values help to break down walls and convert fragmented care into integrated care” (Nester, 2016).

Advocating for our patients and working collaboratively with the other members of the interdisciplinary team will ensure that the patient is educated on all options available and that their preferences are considered when it comes to the care that they will receive.

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Educate yourself
The American Nurses Association conveys that continuing education is “essential to ensure the best patient outcomes” (ANA, n.d.b). To advocate for patients and help create change, it is imperative that the nurse is educated on the current position of the governing bodies, as well as the arguments for and against physician-assisted suicide.

Educate others
Educating patients, other healthcare professionals, and the public is equally as important as educating ourselves. There is a negative stigma associated with physician-assisted suicide and we will not be able to implement change until we can help people understand the truth behind the stigma. By educating others, we can “reframe end-of-life care communication to avoid inflammatory language (i.e. ‘pull the plug’) that undermines improvements in palliative care” (ANA, 2013).

Collaborate
Collaboration amongst the healthcare system is important, regardless of the issue. “A collaborative, interprofessional team supports high quality and safe care, patient and staff satisfaction and engagement, and organizational efficiency and innovation” (Morley & Cashell, 2017). Given the varying viewpoints on the topic of physician-assisted suicide, it is important to recognize that “Adversity and challenges are part of health care delivery” and “It is during these difficult situations that collaboration becomes even more essential” (Bosch & Mansell, 2015).

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I am very passionate about this topic and would love to answer any questions you may have! What is your take on physician-assisted suicide?