The workshop on physician-assisted suicide (PAD) at the October 2015 Canadian Association of Oncology Nurses (CANO/ACIO) drew enough oncology nurses to fill the room far beyond capacity. Following the 2015 decision of the Supreme Court of Canada in Carter v. Canada to allow PAD, professional nursing organizations including CANO/ACIO, the Canadian Nursing Association (CNA), provincial licensing bodies, and health care employers are scrambling to interpret what PAD means to Canadian nursing and nurses.
As one of the attendees at the CANO/ACIO meeting, I took for granted that oncology nurses would generally support PAD. After all, we see some of the most intense physical, emotional, and psychological suffering that the wide world of disease yields. Assisted suicide can offer a controlled end to intractable suffering for a terminally ill patient while respecting personal choice. PAD seems an obvious evolution for modern health care in a way that supports the ethical values health care providers learn about in school: autonomy, beneficence, justice, and nonmaleficence. Instead, I learned from the CANO/ACIO workshop that nurses are conflicted, confused, and perhaps even intimidated about PAD. Emotionally-charged verbal scuffles ensued after this presentation and indeed, having been trained and raised as a nurse in Oregon and Washington (two of four states in the U.S. where PAD is legal), I felt compelled to explore why.
Perhaps one of the root issues is branding. Physician Assisted Suicide (PAS), or Physician Assisted Dying, speaks to the active role of the physician in a way that brings to mind a grim figure whispering “just trust me,” as they offer an ominous vial to a weakened figure reclining in bed. Medical Assistance In Dying (MAID) is slightly less menacing and the acronym provides an air of comfort, helpfulness, cleansing (who doesn’t like maid-service?) and of the feminine. These could be reasons why the U.S. activist movement and corresponding legislation are called “Death with Dignity” and “Patient Choice and Control” thereby removing gender, professional roles and action (“assisted”) from the title, resulting in a more accurate description of what is intended and actually occurring. Many of my Canadian colleagues report they would be more willing to support PAD, “if only it was called something else.” “Aid in Dying” was a popular choice in my informal nursing survey, and the “Medicide” used by Dr. Jack Kevorkian met with no appeal.
The Death with Dignity movement in the United States began in the 1990’s and resulted in legislation being passed in four states: Oregon (Death with Dignity Act, 1998), Washington (Death with Dignity Act, 2008), Vermont (Patient Choice and Control at the End of Life Act, 2013), and Montana (Baxter v. Montana, 2009). New Mexico had a Death with Dignity Act from 2014-2015. California joins the ranks in June 2016, and the Colorado Supreme Court is currently debating a PAD bill. Internationally, Luxembourg (2009), the Netherlands (2002), and Switzerland (1942) have PAD/PAS legislation. According to a systematic literature review by Steck et al. (2013), cancer is the most common reason patients request PAD, followed by multiple sclerosis, ALS (amyotrophic lateral sclerosis, or Lou Gehrig’s disease), and AIDS/HIV.
Canada is a pioneer with a combined PAD/voluntary euthanasia bill, and the duality of the current Carter v. Canada ruling may be a reason for concern. As it stands, physician-assisted suicide laws require that the patient self-administer a fatal drug and the presence of a health care provider is not required or necessary. Within current PAD models including those in the U.S., a patient is prescribed a fatal drug cocktail after extensive discussions with their physician and family, and only after it is determined their disease is terminal. The patient must be deemed mentally sound, competent and able to make an informed decision. This can require a psychiatric evaluation. The patient then fills the prescription and self-administers in a private setting at the time of their choosing. Due to the absence of a health care provider, these drugs are consumed orally as secobarbital capsules followed by pentobarbital liquid.
Voluntary euthanasia (VE) describes the administration by a physician of a fatal drug to a patient and is legal in Columbia (1997), the Netherlands (2002), Belgium (2002), Luxembourg (2009), and Canada (2015, known as the “Quebec protocol”). Voluntary euthanasia carries a heavy burden for the physician, and has the potential to implicate other health care providers (including nurses) in securing intravenous (IV) access, administration of IV or intramuscular medications, and being present when the patient dies. Voluntary euthanasia has far more implications around legality, professional duty, and ethics than PAD, and for this reason should be considered separately and with specific code of conduct requirements. The Canadian Medical Association (CMA) is busy discussing and drafting position papers and legislation drafts to define the physician role in both PAD and VE. The first Canadian death under the Carter v. Canada judgment was the voluntary euthanasia of an Albertan ALS patient by two physicians on private property in Vancouver in February 2016 (Fine & Church, 2016). The second Canadian death occurred in Ontario in March 2016 whereby VE via lethal injection was used for an 81-year old man with lymphoma (Perkel, 2016).
The American Nursing Association (ANA) has an uncompromising approach that correlates with the organizational code of ethics. The ANA released a position statement in 2013 that states, “participation in assisted suicide and euthanasia is strictly prohibited” (p. 9). The CNA and provincial bodies have followed suit. For example, the College of Registered Nurses of British Columbia (CRNBC) released a statement in March 2016 saying that nurses should avoid initiating discussions about PAD with patients and families. Any conversations arising should be immediately referred to a physician, and nurses are advised to consult the Canadian Nurse Protective Society (CNPS) as well as their organizational risk management staff. Portentous stuff, and as some nursing colleagues have inquired, what if you participate in PAD or make a comment conceived as support of PAD and don’t even realize it? With good cause, the CRNBC statement reflects deep-rooted concern about the omitted role of nursing (both registered nurses and nurse practitioners) in the Carter v. Canada judgment. The Association of Registered Nurse of British Columbia (ARNBC) also released a position paper on PAD, expertly written and thorough in scope, highlighting the potential criminality of a nurse providing end-of-life care as an unsuspecting accomplice to PAD/VE should the patient be moving through the legal process. This concern may be valid, but more importantly it illuminates the paradoxical elephant in the room – who better to speak for and with, patients suffering from deeply complex and painful diseases than the front-line caregivers?
An informal review of current Canadian nursing position statements confirms fear of error and culpability while atoning professional autonomy around deciding to work (or not) with these patients. The position statements and articles in nursing journals support changes to the health care system rather than support for PAD. These include advocating for adequate and timely hospice care, increased education and funding around palliative care, and improvements to patient education and treatment of depression in ways that might sway people away from wanting to end their life prematurely. A similar vein of action (or inaction, as the case may be) occurs in U.S. nursing organizations who counsel their members to question the patient’s intention. Examples include asking what reason the patient has for the request. Is suicide the only option, and what accompanying cultural, religious, or social contexts could be involved? According to the ANA, “these questions assist the nurse in better understanding the meaning of these requests and help patients deal with the emotional suffering that may accompany this burden” (2013, p. 8).
The HBO documentary film How to Die in Oregon (2011) provides stark but informative education on what assisted suicide looks like from the patient, physician, and legal perspective. Within this model of care the nursing role is scant or even absent, and may include acting as liaison between patient and physician and perhaps asking probing questions. In my personal hospice and acute care experience working with terminally ill cancer patients and families who were moving through the Death with Dignity process in Oregon, I found their questions thoroughly informed due to an intimate patient-physician relationship and felt tremendous confidence that their choice was the right one for them. As a nurse I was never asked or required to put my license, morals, or professional integrity in jeopardy by employers (private companies), physicians or colleagues. Likewise, I never felt compelled to ask probing questions but rather focused on the here-and-now aspects of patient care and comfort. It is my assumption that with continued vigilance and protagonism by nursing organizations for a collective voice at the PAD table, a similar situation will evolve in Canada so that nurses and patients can preserve autonomy alongside that precious air of mutual respect.
References and Further Reading
American Civil Liberties Union of Montana. (2013). Baxter v. State of Montana. Retrieved from aclumontana.org/baxter-v-state-of-montana/
American Nursing Association. (2013). ANA position statement: Euthanasia, suicide, and aide in dying. Retrieved from www.nursingworld.org/euthanasiaanddying
Association of Registered Nurses of British Columbia (ARNBC). (2016). Nurses’ and nursing’s role in supporting a patient-centered approach to physician-assisted death. [Position Statement]. Retrieved from www.arnbc.ca/pdfs/resources/publications/position-statements/PS-Physician-Assisted-Death.pdf
Canadian Medical Association. (2016). Developing a Canadian approach to assisted dying. Retrieved from www.cma.ca/En/Pages/end-of-life.aspx
Canadian Nurses Association. (2016). Canadian Nurses Association welcomes report on medical assistance in dying. Retrieved from www.cna-aiic.ca/en/news-room/news-releases/2016/canadian-nurses-association-welcomes-report-on-medical-assistance-in-dying
Carter v. Canada. Supreme Court Judgments. 6 Feb. 2015. Retrieved from scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do
Fine, S., & Church, E. (1 March, 2016). ALS sufferer first Canadian to receive judge’s approval for assisted death. The Globe and Mail. Retrieved from www.theglobeandmail.com/news/national/calgary-woman-first-to-receive-judge-approved-assisted-death/article28974818/
How to Die in Oregon. (2011). HBO Documentary Web site. Retrieved from www.hbo.com/documentaries/how-to-die-in-oregon/
Oregon Health Authority. (1994). The Oregon Death with Dignity Act: Oregon Revised Statutes. Retrieved from public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/statute.pdf
Perkel, C. (17 March 2016). Ontario assisted dying: Court allows 81-year old man to have doctors help him die. The Huffington Post. Retrieved from www.huffingtonpost.ca/2016/03/17/canada-doctor-assisted-de_n_9486198.html
Steck, N., Egger, M., Maessen, M., Reisch, T., & Zwahlen, M. (2013). Euthanasia and Assisted Suicide in Selected European Countries and US States: Systematic Literature Review. Medical Care, 51(10), 938-944 7p. doi:10.1097/MLR.0b013e3182a0f427
Vermont Department of Health. (2013). Patient Choice and Control at the End of Life Act (Act 39). Retrieved from www.leg.state.vt.us/docs/2014/Acts/ACT039.pdf
Washington State Department of Health. (2016). Washington Death with Dignity Act, Initiative 1000. Retrieved from www.wsha.org/our-members/projects/end-of-life-care-manual/death-with-dignity-act/
Jennifer M.L. Stephens is an experienced oncology nurse who has worked in hospice, palliative care, acute and critical care. American by birth, she immigrated to Canada in 2007 and has been working for the Leukemia/Bone Marrow Transplant Program of B.C. on the inpatient unit at Vancouver General Hospital. Jennifer is a doctoral candidate in nursing at the University of British Columbia, with dissertation work focusing on disease identity for adult haematology oncology patients.