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Practice comment

"Beware the implications for nurses of assisted dying law"

While imminent changes to the law are unlikely, the issue of assisted dying is not going to go away

Public and professional reaction to the recent report from the Commission on Assisted Dying has been predictably emotive. Whatever your opinion of the findings, the authors are to be commended for the thoroughness with which they addressed the issues, and the humanity that comes through their arguments for revised legislation.
Unfortunately, this can lull the unwary into acceptance of what seems on paper to be perfectly reasonable - namely to allow terminally ill people of sound mind the option of active help to commit suicide.
The report is clear that the primary responsibility for consulting, drug prescription, assistance at the bedside and follow-up support lies with doctors. There is a naivety here that fails to acknowledge nurses’ role in supporting patients and families, and whether they are required to be present when the intervention takes place.
The authors expect that, should legislation be forthcoming, most assisted suicide will be in the home, which puts district and community palliative care nurses at the forefront of this proposal.
A colleague and I recently taught a mixed group of health professionals and gave them a questionnaire that presumed that such legislation was in place. We asked about the place of the suicide, who would attend, the licensing and inspection of premises other than the home, conflict with codes of conduct, clinical protocols and procedures, education and whether they would consider taking part.
Few had even considered that assisted suicide might take place outside the home, and many felt some other health professional should be there as a safeguard.
No one wanted to be part of it, while acknowledging that no conscience clause exists. No one had thought about the need for procedures and protocols and fears were voiced about the legal ramifications.
The session was a success because the participants had been confronted with a potential future reality, which none had considered.
The report mentions implications for nurses once. It states: “Professional bodies, including the General Medical Council and the Nursing and Midwifery Council would need to develop codes of practice to guide appropriate professional conduct and specify appropriate training and levels of experience for professionals who take a role in assisted dying.”
This report is unlikely to lead to legislation. But, make no mistake, while no self-respecting government could be seen to endorse the proposals - particularly in the wake of scandals around care of older people - this issue will not go away.
Nurses must remain open minded, well informed and ready to respond with skill and humanity to the difficult conversations that accompany requests for help to die. We do know where support is available such requests often recede, which is a powerful argument for better end-of-life services.

Robert Becker is Macmillan senior lecturer in palliative care, Staffordshire University and Severn Hospice, Shropshire

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Readers' comments (12)

  • Glad there has been a reaction to Ass' Dying Report. There are so many of us that dont want to see the law changed and even more would not want to have to participate in assisted deaths, esp long term carers. I am so glad of the help and advice I receive from the organisation Nurses Opposed to Euthanasia and CMF. We are all sympathetic towards suffers-that's our job but we must ask for more palliative care training to ensure we give them the best possible symptom control and counselling. When that's in place, there are very, very few references to wanting to opt out of life.

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  • George Kuchanny

    Thanks for the article and most especially thank you Sally for your comment.

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  • I confess that I have not read this latest report but over a nursing career of nearly 40 years this debate has been ever present.

    I fully acknowledge the tremendous progress in palliative care and pain control and thankfully the drawn out and agonising deaths I have witnessed in my time are now few and far between - BUT THEY STILL DO OCCUR.

    As good as our medical management is it is not infallible and for some people the end of their lives is an unpleasant and painful process for both the individual and their family.

    There is also the quality of life issue.
    As is demonstrated by the increasing numbers of people who seek the DIGNITAS option some people simply wish to take the ultimate control over their condition and if they decide that for example life in a wheelchair with the anticipation of becoming progressively more dependent on other people is not acceptable to them how can a civilised society deny them the option of not wishing to live such a life.

    A difficult and emotive issue it most certainly is but it is not going to go away just because it feels uncomfortable. At least we are more comfortable debating it openly now - which I think is a great step forward.

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  • Yes, it is good we can debate it, Mr. Toy and, yes maybe some do not get the best care at the end of life, but, surely they deserve to have it, esp. symptom control and we must push for better training in this field. I do not find killing them to be an option. It is a sad reflection on our profession that people are frightened of being dependent on us, even though they pay our wages, indirrectly, and it is our job to look after them. They are frightened of pain, even more than death itself! This shouldn't be. We must strife to prove that we will deal with all their problems and give them the help they need to die peacefully.
    As far as wanting to die rather than be in a wheelchair, that decries the valuable lives of those who do have to endure that. Most have rewarding, useful lives and remain positive and happy. It's suprising how one's need stimulates others to help and get the satisfaction that that brings. Pain, suffering diababilities ADD to our experience-both for the carer and the cared for. So many testify that their relative/friend/client's end gave them a new perspective on life. It's not undignyfied and it can be a life-changing experience, if we all made the best of it. Death is so final and life is precious.

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  • michael stone

    Bill Toy | 2-Feb-2012 1:38 pm

    Thanks for that Bill, writing as a layman - I watched a friend dying from cancer and 'aware of agony but nothing else' for at least a week.

    I am seriously annoyed by those people who claim that adequate pain relief can ALWAYS be provided - they should keep that as an opinion for THEIR OWN pain, and not for other people's pain !

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  • pain relief can be provided for most but sadly with individual differences and idiosyncrasies there will always be exceptions.

    unfortunately there are also failures in the administration of adequate pain relief where the patient is badly let down by those to whom their care is entrusted.

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  • pain relief can be provided for most but sadly with individual differences and idiosyncrasies there will always be exceptions.

    unfortunately there are also failures in the administration of adequate pain relief where the patient is badly let down by those to whom their care is entrusted.

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  • Hello Sally - thanks for your response.

    I can see that this is an important issue for you, but would ask you to read my post again.

    I'm not advocating 'killing' people because we deem it prudent, and I'm not deriding the pleasure and sense of closeness that some people get from caring or being cared for - I'm just saying that people should be given the CHOICE whether they want to continue living with a terminal illness or what for them is an unacceptable quality of life.

    Another very emotive parallell is abortion - where views are often violently opposed - yet that has not stopped us in this civilised country supporting a womans right to choose and legalising abortion pretty much on demand (subject to certain criteria).

    Surely this same right to choose should apply to end of life.

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  • michael stone

    Bill Toy | 7-Feb-2012 2:08 pm

    Bill, the issues of administering pain relief which to accomplish its objective might also actually kill the patient, what assisted suicide is, and refusals of treatment are not identical.

    While mentally capable, a person can refuse all offered treatment. And it is very unclear whether giving pain releif which is intended to relieve pain and yet as a side-effect could possibly hasten death, is assisted suicide (I personally, think not - but I don't enjoy pain, myself).

    It gets very 'entrenched' !

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  • Hello Michael

    Yes - I see the distinction and this is the way we have to practices at present.

    The giving of near terminal doses of pain relief under the guise of 'treatment' has been a way of staying within thelaw and bounds of ethical practice - but as you have pointed out by your own experience - it sadly is not enough im some cases.

    I am simply advocating for the RIGHTfor a person - deemed of sound mind and having the capacity to consent - to say - 'right - enoughs enough - I no longer wish to live with this pain - or - I no longer have quality of lifE and so I want to end it'

    Having the right to choose doesn't make it mandatory but not having the right to choose in our own country means we have to seek that option elswhere in order to protect those who might assist us in our wish. Its playing the legal game and I think its time we brushed that aside.

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  • michael stone

    Bill, I think we basically 'stand together' on assisted suicide - although my concern isn't assisted suicide (too hard) but what actual wording on an Advance Decision will work for a 'sudden' death - in other words, how do you exercise your right to say 'whatever has stopped my heart, let me die in peace' ?

    And that issue gets 'tangled up' with the assisted suicide debate, for reasons which somewhat baffle me ! It also gets tangled up with VoD behaviour, equally baffling !

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  • michael stone

    Re:

    'There is a naivety here that fails to acknowledge nurses’ role in supporting patients and families, and whether they are required to be present when the intervention takes place.
    The authors expect that, should legislation be forthcoming, most assisted suicide will be in the home, which puts district and community palliative care nurses at the forefront of this proposal.'

    If assisted suicide were legalised, I can see no reason why nurses need be present, and personally I would argue that nurses should not be present. You need a doctor present to certify the death, and deal with any problems - but why would a nurse need to be present, and more pertinently, why would a nurse wish to be present ?

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