Should assisted suicide be only physician assisted? University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel

Health Care Providers' Experiences with Implementing Medical Aid-in-Dying in Vermont: a Qualitative Study

BACKGROUND

The evolving legal landscape for medical aid-in-dying (AID) in the USA raises clinical and public health challenges and concerns regarding how health care providers will accommodate AID while expanding access to high-quality end-of-life care.

OBJECTIVE

To describe Vermont health care providers' experiences practicing under the "Patient Choice and Control at End of Life" Act.

DESIGN

Qualitative semi-structured interviews analyzed using grounded theory.

PARTICIPANTS

The larger study included 144 health care providers, terminally ill patients, caregivers, policy stakeholders, and other Vermont residents working in 10 out of Vermont's 14 counties. This article reports on a subset of 37 providers who had clinical experience with the law.

MAIN MEASURES

Themes from interviews.

KEY RESULTS

Physicians were roughly split between hospital and community-based practices. Most were women (68%) and the largest subgroup specialized in internal or family medicine (53%). Most of the nurses and social workers were women (89%) and most worked for hospice and home health agencies (61%). We identified five domains in which participants engaged with AID: (1) clinical communication and counseling; (2) the Act 39 protocol; (3) prescribing medication; (4) planning for death; and (5) professional education. How providers experienced these five domains of clinical practice depended on their practice setting and the supportive resources available.

CONCLUSION

Health care providers' participation in AID involves clinical tasks outside of responding to patients' requests and writing prescriptions. Research to identify best practices should focus on all domains of clinical practice in order to best prepare providers.

Implementation of Medical Assistance in Dying: A Scoping Review of Health Care Providers' Perspectives

RESEARCH AIMS

With the growing interest in Medical Assistance in Dying (MAiD), understanding health care professionals' roles and experiences in handling requests is necessary to evaluate the quality, consistency, and efficacy of current practices. This scoping review sought to map the existing literature on health care providers' perspectives of their involvement in MAiD.

METHODS

A scoping review was conducted to address the following: 1) What are the roles of diverse health care professionals in the provision of MAiD? and 2) What professional challenges arise when confronted with MAiD requests? A literature search in electronic databases and gray literature sources was performed. Articles were screened, and a thematic content analysis synthesized key findings.

RESULTS

After evaluating 1715 citations and 148 full-text papers, 33 articles were included. Perspectives of nurses (n = 10), physicians (n = 7), mental health providers (n = 7), pharmacists (n = 4), social workers (n = 3), and medical examiners (n = 1) were explored. Professional roles included consulting/supporting patients and/or other staff members with requests, assessing eligibility, administering/dispensing the lethal drugs, providing aftercare to bereaved relatives, and regulatory oversight. Challenges included lack of clear guidelines/protocols, role ambiguity, evaluating capacity/consent, conscientious objection, and lack of interprofessional collaboration.

CONCLUSION

Evidence from various jurisdictions highlighted a need for clear guidelines and protocols that define each profession's role, scope of practice, and legal boundaries for MAiD. Comprehensive models of care that incorporate multidisciplinary teams alongside improved clinician education may be effective to support MAiD implementation. Little is known about health care providers' perspectives in handling requests, especially outside physician practice and nursing.

Comment la marge peut-elle déplacer le centre en matière d’accompagnement de fin de vie ?

Les associations d’aide au suicide en Suisse peuvent assister des personnes âgées institutionnalisées à certaines conditions. Cet article présente les résultats préliminaires d’une étude qualitative menée auprès de professionnel.le.s d’établissements médico-sociaux pour personnes âgées confronté.e.s à l’assistance au suicide. Il présente quelques défis que celle-ci pose à la mission professionnelle et au fonctionnement institutionnel ainsi qu’au positionnement personnel. Le suicide assisté en institution engendre de nouvelles pratiques par ajustements successifs, entre résistance et normalisation, l’enjeu ultime étant l’intégration ou non de la mort par suicide assisté comme une des modalités de l’accompagnement de fin de vie au sein des institutions.

The debreather: a report on euthanasia and suicide assistance using adapted scuba technology

In response to the general prohibition of euthanasia and assisted suicide, some right-to-die activists have developed non-medical methods to covertly hasten death. One such method is a "debreather," a closed system breathing device that laypersons can use to induce hypoxia for persons seeking euthanasia or assisted suicide. This article presents data from nine cases where the debreather was used on humans, resulting in eight deaths. The covert properties of the debreather make it almost impossible for medical examiners and law enforcers to detect its use. Clandestine behavior circumvents legal forms of social control and challenges models for regulated, medicalized euthanasia and assisted suicide. The debreather compromises the ability of forensic investigators to assign an accurate cause and manner of death, and this raises implications for law enforcement, vital statistics, and research into the causes of death. The involvement of lay organizations in euthanasia and assisted suicide means that effective social policy on right-to-die issues must take into account their activities as well as those of other health professionals.

Collaborated death: an exploration of the Swiss model of assisted suicide for its potential to enhance oversight and demedicalize the dying process

Death, like many social problems, has become medicalized. In response to this medicalization, physician-assisted suicide (PAS) has emerged as one alternative among many at the end of life. And although the practice is currently legal in the states of Oregon and Washington, opponents still argue that PAS is unethical, is inconsistent with a physician's role, and cannot be effectively regulated. In comparison, Switzerland, like Oregon, permits PAS, but unlike Oregon, non-physicians and private organizations play a significant role in assisted death. Could the Swiss model be the answer? The following essay explores the Swiss model of assisted suicide for its potential to enhance the regulation of PAS, reduce physician involvement, and perhaps demedicalize the way we die.

Factors related to the involvement of nurses in medical end-of-life decisions in Belgium: A death certificate study

BACKGROUND

Although nurses play an important role in end-of-life care for patients, they are not systematically involved in end-of-life decisions with a possible or certain life-shortening effect (ELDs). Until now we know little about factors relating to the involvement of nurses in these decisions.

OBJECTIVE

To explore which patient- and decision-characteristics are related to the consultation of nurses and to the administering of life-ending drugs by nurses in actual ELDs in institutions and home care, as reported by physicians.

METHOD

We sampled at random 5005 of all registered deaths in the second half of 2001--before euthanasia was legalized--in Flanders, Belgium. We mailed anonymous questionnaires to physicians who signed the death certificates and asked them to report on ELDs, including nurses' involvement.

RESULTS

Response rate was 59% (n=2950). Physicians reported nurses involved in decision making more often in institutions than at home, and more often in care homes for the elderly than in hospitals (OR 1.70, 95% CI 1.15, 2.52). This involvement was more frequently when physicians intended to hasten the patient's death than when they had no such intention (institutions: OR 2.05, 95% CI 1.41, 2.99; home: OR 2.04, 95% CI 1.19, 3.49). In institutions, this involvement was also more likely where patients were of lower rather than higher education (OR 2.95, 95% CI 1.49, 5.84). The administering of life-ending drugs by nurses, as reported by physicians was also found more frequently in institutions than at home, and in institutions more frequently with lower rather than higher educated patients (p=.037).

CONCLUSIONS

These findings raise questions about physicians' perception of the nurse's role in ELDs, but also about physicians' skills in interacting with all patients. Education and guidelines for physicians and nurses are needed to optimize good communication and to promote a clearer assignment of responsibilities concerning the execution of those decisions.

Assessment of requests for assisted suicide by a Swiss right-to-die society

Non-physician volunteers of Exit, the largest right-to-die organization in Switzerland, play an important role in assisted suicide. They conduct assessments and deliver lethal medications for a member to self-administer. This study analyses the content of 114 intake sheets (checklists) of Exit members whose requests for assisted suicide were granted in an effort to examine the frequency of depression and whether their relatives agreed with the member's decision to commit suicide (2 questions that can help increase the likelihood that the member's decision was both informed and voluntary). Exit's paperwork indicated that depression was found to exist in 27% of the cases, was more common among those under 65, and relatives explicitly disagreed with the member's decision in 5% of the cases.

Role of non-governmental organisations in physician assisted suicide

Could right to die organisations be part of the solution to the many ethical difficulties doctors face over assisted suicide? Stephen Ziegler and Georg Bosshard examine how two organisations in Switzerland and Oregon help people die

Responding to desire to die statements from patients with advanced disease: recommendations for health professionals

It is not uncommon for patients with advanced incurable disease to express a desire to hasten their death. Health professionals often have difficulty responding to such statements, and find it challenging to ascertain why these statements are made. Health professionals may struggle to determine whether a 'desire to die' statement (DTDS) is about a request for hastened death, a sign of psychosocial distress, or merely a passing comment that is not intended to be heard literally as a death wish. Given the lack of guidelines to assist health professionals with this issue, we have prepared multidisciplinary recommendations for responding to a DTDS, underpinned by key principles of therapeutic communication and a systematic review of empirical literature. Where the relevant literature was lacking, the recommendations were drafted by the authors (clinicians and/ or academics from the following disciplines: nursing, medicine, psychiatry, psychology, sociology, aged care and theology), based on their expert opinion. Multiple drafts of the recommendations were circulated to the authors for refinement until consensus was reached. Strategies for advancing the evidence base for the maturation of guidelines in this area are offered.

Desire for hastened death in patients with advanced disease and the evidence base of clinical guidelines: a systematic review

PURPOSE

Patients' desire for hastened death within the context of advanced disease and palliative care is a controversial topic, frequently discussed in the international literature. Much of the discussion has focused on opinion and debate about ethical matters related to hastened death. Not many research studies seem to have specifically targeted why palliative care patients may desire hastened death, and few have focused on clinical guidelines for responding to such requests.

METHODS

Using a systematic literature review process, we evaluated the research evidence related to the reasons patients express a desire for a hastened death, and the quality of clinical guidelines in this area.

RESULTS

Thirty-five research studies met the inclusion criteria related to reasons associated with a desire for hastened death. The factors associated with a desire to die were often complex and multifactorial; however, psychological, existential and social reasons seem to be more prominent than those directly related to physical symptoms, such as pain. Much of the evidence supporting the reasons for these statements is based on: (a) patients' perceptions of how they may feel in the future, and (b) health professionals' and families' interpretations of why desire to die statements may have been made. Several publications provided expert opinion for responding to requests for physician-assisted suicide and euthanasia. In keeping with this limited research base, there is a lack of evidence-based guidelines for clinical care that addresses the desire to die among terminally ill patients. Most literature has focused on discipline specific responses, with minimal exploration of how clinicians might respond initially to a statement from a patient regarding a desire to die.

CONCLUSIONS

In order to advance understanding of the complex issue of desire for hastened death in the context of palliative care, research should focus on studies with patients who have actually made a desire to die statement and the development of guidelines to help health professionals respond. Direction for research in this area is described.

Attitudes and experiences of Oregon hospice nurses and social workers regarding assisted suicide

BACKGROUND

When the Oregon Death with Dignity Act (ODDA) legalizing physician-assisted suicide was enacted into law in 1997, Oregon hospice clinicians were uncertain how involved they would be with patients who wanted this option. However, 86% of the 171 persons in Oregon who have died by lethal prescription were enrolled in hospice programmes.

METHOD

A mailed questionnaire was sent to all hospice nurses and social workers in Oregon in 2001 (n=573) to assess their attitudes about legalized assisted suicide and interactions with patients concerning this issue. Responses from 306 nurses and 85 social workers are included in this report.

FINDINGS

Almost two-thirds of respondents reported that at least one patient had discussed assisted suicide as a potential option in the past year. Social workers were generally more supportive of both the ODDA and of patients choosing assisted suicide compared to nurses. Twenty-two per cent of all respondents were not comfortable discussing assisted suicide with patients. Ninety-five per cent of both groups, however, favoured hospice policies that would allow a patient to choose assisted suicide while enrolled in hospice and allow hospice clinicians to continue to provide care.

INTERPRETATIONS

Nurses and social workers in hospices and other settings can expect to encounter patient questions about physician-assisted suicide, whether legalized or not, and must be prepared to have these discussions. Most hospice professionals in Oregon do not believe that assisted suicide and hospice enrollment are mutually exclusive alternatives.

Involvement of nurses in physician-assisted dying

BACKGROUND

Death in modern societies is often preceded by medical end-of-life decisions. Empirical research on these end-of-life decisions focuses predominantly on the physicians' role. Little is known about the role of other health care workers, especially that of nurses.

AIM

This paper reports the findings of a study that investigated how often nurses are consulted by physicians in the decision-making process preceding end-of-life decisions and how often nurses participate in administering lethal drugs in end-of-life decisions.

METHOD

Data were collected within a nationwide cross-sectional retrospective death certificate study in Flanders, the Dutch-speaking part of Belgium. We selected 3999 deaths, a 20% random sample of all those occurring during the first 4 months of 1998. Anonymous questionnaires were mailed to the physicians who signed the death certificates. Several questions concerned the involvement of nurses in end-of-life decisions.

RESULTS

We received 1925 valid questionnaires. For all reported end-of-life decisions (39.3% of all deaths in Flanders), physicians provided information about the involvement of nurses. Physicians consulted at least one nurse in 52% of end-of-life decisions cases occurring in institutions, compared with 21.4% of such cases at home. Nurses administered lethal drugs in 58.8% of euthanasia cases occurring in institutions and in 17.2% at home. For cases in which life was ended without the patient's explicit request because, predominantly, they were too ill to do so, these percentages were respectively 82.7% and 25.2%. In institutions, nurses mostly administered drugs without the attendance of a physician who had prescribed the drugs.

CONCLUSIONS

Nurses in Belgium are largely involved in administering lethal drugs in end-of-life decisions, while their participation in the decision-making process is rather limited. To guarantee prudent practice in end-of-life decisions, we need clear guidelines, professionally supported and legally controlled, for the assignment of duties between physicians and nurses regarding the administration of lethal drugs to reflect current working practice. In addition, we need appropriate binding standards governing mutual communication about all end-of-life decisions.

Assisted Dying and End-of-Life Symptom Management

This qualitative study aimed to describe symptom management strategies oncology nurses have used in responding to and preventing requests of terminally ill patients with cancer for assisted dying (AD). The study involved secondary analysis of written stories from 36 nurses who agreed to describe their experiences with a request for assisted dying. Of the 36 nurses, 12 refused to support patient requests for AD and described their attempts to control the circumstances of dying by controlling symptoms. The remaining 24 nurses denied ever receiving requests for AD and described symptom management practices believed to prevent such requests. Data were analyzed using Denzin's process of interpretive interactionism. Two themes emerged from the participant's stories: alternative strategies for AD and prevention of requests for AD. The participants shared many examples of clinical interventions and other features of nursing responses to relieve or prevent suffering including physical, emotional, and spiritual care practices; comfort and medication management; and service as teacher-advocate. Both the nurses who had received requests for AD and those who had not used a variety of similar symptom management approaches to alleviate suffering. In doing so, these nurses upheld current standards of both their professional and specialty organizations.

Policy and psychosocial considerations associated with non-physician assisted suicide: a commentary on Ogden

The report by Russel Ogden (2001) on a conference where devices designed to facilitate death were displayed and discussed highlights how far some individuals will go if they are committed to helping suffering people die. In this commentary, the author discusses the federal policy developments that have contributed to this movement and then expresses his concerns about using lay people to provide assistance with hastening death.

Physician-assisted dying: review of issues and roles for health psychologists

The authors review the recent empirical and theoretical literature on physician-assisted dying (PAD) since implementation of the Oregon Death With Dignity Act (ODDA) in 1997. The authors provide a brief overview of end-of-life practices; consider ethical and practical issues regarding PAD; outline governments' acts and health care organizations' current codified principles regarding PAD, including the American Psychological Association's goal to increase the visibility of psychology in end-of-life issues; examine recent data pertinent to ODDA implementation and psychologists' attitudes regarding PAD; and outline potential roles for health psychologists responding to requests for PAD and implementing PAD (where it is legal). Health psychologists can assume at least 4 roles regarding PAD: (a) policy advocates, (b) educators, (c) practitioners, and (d) researchers.

The role of guidelines in the practice of physician-assisted suicide. University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel

Oregon has legalized and implemented physician-assisted suicide, while observers argue about the moral import of attempting to formulate guidelines; the utility any set of guidelines can have for physician practice, health care providers, patients, or families; and whether guidelines can really protect against harm or abuse. What were once theoretical questions have taken on new urgency. The debate over the value and power of guidelines includes the following questions: What has been the experience of efforts to implement physician-assisted suicide using consensus guidelines? What goals are guidelines intended to serve? Who should formulate guidelines? What features should be reflected in any proposed guidelines to make them practical and to permit achievement of their goals? Are there any fundamental obstacles to the creation or implementation of guidelines? Is dying a process that is amenable to direction under guidelines, be they issued by physicians, departments of health, blue ribbon panels, or other regulatory bodies? This paper explores these questions as physician-assisted suicide becomes legal.