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Practice comment

'If assisted suicide is legalised, are nurses best placed to do it?'


We have a strange relationship with death.

It pervades our games, books and movies to the point that we’re desensitised to it but factual depictions often heighten sensitivities to the levels of censorship. Choosing to Die, Terry Pratchett’s documentary on assisted suicide, is an example – despite depicting a legal reality and dealing sensitively with participants, it produced 900 complaints and claims that it was “repugnant” and “disgraceful”.

I watched it with morbid curiosity and professional interest. The “escorts” – staff coordinating the assisted suicide – particularly caught my attention. Their role was clear, but we had no sense of how their experience and training led them to be considered the most appropriate people to carry it out. This begs the question: if a service that administers merciful death becomes a reality, who is best placed to deliver it?

Assisted suicide is legal in several jurisdictions, including Belgium, Luxembourg, the Netherlands, Switzerland, Oregon, Washington and Montana. Generally, the barbiturates used have to be prescribed by a medic and patients have to take them themselves; nurses are involved in every other part of the process.

The Oregon Nurses Association produced guidelines of acceptable actions for nurses who choose to participate. These include: assessing decisional capacity and discussing alternatives; dealing with spiritual and practical matters during the preparation time; providing care and support during the dying process; and all the administration and coordination connected with the act – everything, in fact, other than prescribing and administering the drug.

But there has been a new development: in the US three physicians contended that nurses are best suited to carry out all roles central to assisted suicide including, where legal, prescribing and administering the lethal dose. Is this as shocking as it seems?

Practically, nurses are best placed to coordinate and administer holistic care for the dying. Prescribing and administering medication is not beyond us and our duty of care, arguably, puts us in a better philosophical position than a physician’s Hippocratic oath (“I will not give a lethal drug to anyone if I am asked”). Practically and philosophically there is no reason for us  not take up a central role on this issue.

But do we want to? Would our responsibilities include assisted death because we are better placed to do it or because of a shortage of willing doctors? Could nurses agreeing to assist be addressing their own pain in seeing suffering rather than thinking of the patient’s best interests?

Perhaps this poisoned chalice should be shared to create a multidisciplinary process including social workers and religious leaders. It may seem like simply moving from hangman to firing squad but, if assisted suicide does become a reality, surely anything that helps make it more humane, effective and confined to appropriate cases is welcome? Either way, we must take an active role in any policy development so we direct it, rather than allow others to define it for us. 

Stephen Riddell is a district nurse working in Dumfries and Galloway


Readers' comments (5)

  • michael stone

    Clinicians seem to have more than enough problems getting their heads around a person’s legal right to refuse life-sustaining treatments, let alone coping with assisted suicide. And assisted suicide is not one my areas of interest, so I have only very briefly thought about it. So the following are merely my ‘instincts’ for assisted suicide, if the law were changed to allow it (and this goes for England, where suicide is already legal):

    1) Suicide is legal because our law puts a person’s self-determination above the requirement that his life must be preserved, so if assisted suicide were to be legalised, it would be based on the principle of self-determination;

    2) Therefore, following from 1), the law could require that the person himself ‘threw the switch’;

    3) If so, then the role of clinicians would be to advise on the ‘best’ method of killing oneself, and the provision of any necessary equipment and drugs – it need not necessarily extend to the ‘switch pulling’ (and I would be surprised if it did extend to that, because if the patient could clearly request the assistance, the patient should also be able to throw the switch himself, even if this required technological assistance);

    4) I think that nurses are the second most likely group in terms of being able to understand why a person would request assisted suicide, after the person’s close family (etc) and ahead of doctors. But I do not like the idea of nurses even being involved (as in physically present at) in actual assisted suicides – I don’t like this (psychological) switch from trying to keep people alive, to assisting dying. I think relatives might ‘need’ to be present for psychological reasons, and I think a doctor needs to be present for clinical reasons – but I don’t really think nurses, would need to be present.

    I also think that for most people, it becomes easier to understand why someone might request assisted suicide – why ‘I would prefer to be dead/not wake up again’ – as a person becomes older: so 50 yr olds can probably ‘understand’ that, better than 20 yr olds, although that is not connected directly with a person’s profession or role;

    5) If the law allowed someone other than the patient to ‘pull the switch’, then I think it should be made impossible to be certain that any particular person had pulled it: the old ‘firing squad with some rifles unloaded’ principle;

    But I’m pretty certain it will be some time before England has a law allowing assisted suicide – it would be a good start, in this general area of suffering before death, to sort out what types of pain relief, sedation, etc, can be provided legally at present, and for these to be universally available to patients. There is far too much ‘fudging and back-covering’ going on at present, for the situation to be at all satisfactory from the position of those patients who are currently dying in pain, and who wish to not suffer from relievable distress.

    But at least many doctors are starting to discuss the issues – there is pressure for improvement in this area. We (society and clinicians) should not be making dying people, who request pain-relief or permanent sedation where pain-relief is inadequate, suffer unnecessarily ! And using a limited amount of legal uncertainty, to leave a lot of dying patients in relievable pain and distress, is in my opinion (as a patient/relative) cowardly and unacceptable.

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  • Assisted suicide is wrong. We have no control over when we enter this world and so we should have no control when we leave it. Simple.

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  • "'If assisted suicide is legalised, are nurses best placed to do it?'"

    N O !

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  • No. Patients trust nurses. We are their advocate and should be able to address all their fears and deal with symptoms. Fear is a great obstacle and if they fear they may be killed, sorry, euthanised, they may not come into hospital for help. At a debating society meeting on this topic, a Palliative Care Consultant said that she believed they would not ask about Assisted death if they really thought she would act on it, but if approached regarding that, they would talk through everything and allay fears. Very very few symptoms cannot be controlled and death is peaceful and dignified with the proper care. I hope Drs will continue their rejection of it and hope nurses will too.

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  • michael stone

    sally carson | 14-Jan-2012 1:13 am

    You write:

    'Very very few symptoms cannot be controlled and death is peaceful and dignified with the proper care.'

    A friend of mine, was in a nursing home when he died. Despite a brief removal to somewhere supposedly expert in pain control, he was returned to the nursing home in a condition which which can only be described as 'delirious but clealry in continuous agony' - he was in that condition for about a week, before his eventual death.

    I do not believe that pain and distress can always be relieved, unless a person is placed into deep continuous sedation: there is a debate, about whether continuous sedation should be supplied if a patient requests it.

    Many experts in palliative care, also accept that 'adequate pain relief' is not always possible.

    And as for 'if they fear they may be killed, sorry, euthanised' - the question is about assisted suicide, not the much vaguer 'euthanasia', and to conflate acceding to someone's request that they be helped to die in a clinically painless way, with murder strikes me as very peculiar.

    There is also the question, of suicide while assisted suicide isn't legal - how exactly does an EoL patient, who finds his or her suffering intolerable, commit suicide at present ? Methods such as paracetamol overdoses are sometimes attempted, something I think should be prevented if possible, and perhaps if assisted suicide were legal such things would happen less, with a reduction in suffering.

    But I don't like, at a 'deep' level, clinicians being involved in assisting suicides (beyong providing the means), as it is the opposite to what clinicians are usually trying to do, which is to keep people alive. And I definitely do not like the idea of nurses being involved, as I regard the 'empathic' aspects of being a good nurse, as too problematic: to properly 'accept' that suicide is the best course of action, you need to 'deeply feel the person's pain', and a relative will do that, but not very often. Even properly feeling this pain once, is damaging for a relative - clinicians must not attempt to feel that 'deep pain' for dying patients, or they would be seriously altered psychologically.

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