As reported to Chris Pirschel, Staff Writer, by Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN
When physician-assisted death mandates were passed in states like Oregon, Washington, and California, guidelines were established for practitioners as part of election mandates.
However, in states like Montana and Vermont, the legalization of assisted death went through the legislature without process and practice guidelines. Therefore, practitioners have little or no framework to implement the process of medical aid in dying.
The Hospice and Palliative Nurses Association (HPNA) spent two years exploring the issue of medical aid in dying on the spectrum of end-of-life care to update its position statements through a two-pronged approach. HPNA revised the position statement Physician-Assisted Death/Physician-Assisted Suicide and updated the document Guidelines for the Role of the Registered Nurse and the Advanced Practice Registered Nurse When Hastened Death Is Requested. Nurses are not part of the process once patients choose physician-assisted death, nor are they involved in writing prescriptions for it. Therefore, HPNA’s position is that physician-assisted death/physician-assisted suicide is not part of palliative care. However, our organization recognizes that it’s a legal end-of-life option for terminally ill patients in some states and many nurses need to navigate care in that environment.
Although nurses don’t have a mandated role in the medical aid in dying process, they have a role to ensure patients are evaluated on the many different layers of spiritual, psychological, social, and emotional dimensions of care and to make sure that those needs are being met. In many cases, if a patient approaches the care team about assisted death, it’s an indication of distress that something is not being managed well. With physical symptoms such as pain or other symptoms such as spiritual and psychological distress, nurses can help patients understand that with current evidence-based practice, issues associated with advanced disease and end of life can be managed with numerous pharmacologic and nonpharmacologic options.
The hospice or palliative care team must evaluate the reason for distress and collaborate to alleviate it. Interdisciplinary experts from throughout the spectrum of care can help look at individual needs and address them appropriately. The palliative care team is always open and willing to have end-of-life conversations with patients to explore any unaddressed issues and ensure that patients maintain dignity, respect, and the feeling that no one will abandon them.
Many ethical and moral dilemmas can arise among the care team when a patient requests assisted death. However, nurses must consider their own personal and professional values and start the team discussion to develop a consistent process of what to do when patients brings up assisted death. The Guidelines for the Role of the Registered Nurse and Advanced Practice Nurse When Hastened Death Is Requested can serve as a guide for this.
For some nurses, individual spiritual and ethical influences may make it difficult to have these discussions with their patients. However, it’s important to promote the conversation that it’s about the patient—not about us. These are nuanced, gentle discussions, and if a nurse determines, “I don’t really agree with that,” or “My religious convictions do not allow me to discuss this,” the principle of conscientious objection may be an option. Nurses should ensure their patients are transitioned to a healthcare professional who can address their needs while caring for them in the meantime so patients don’t feel abandoned.
Ultimately, nurses need to be open to listening to their patients, because it’s their story and their process. Listening alerts to the presence of spiritual or emotional distress, where we can address fears and concerns and individualize a care plan. Palliative care is always about patient-centered, family-focused care, and it’s crucial to understand where nursing fits into end-of-life discussions, especially as assisted death becomes more widely recognized.