Guidelines help nurses balance medicine, morals

When Oregon voters legalized assisted suicide with the Death with Dignity Act in October 1997, the attention in the medical community was focused largely on the role and responsibilities incurred by physicians treating the seriously ill. However, the state’s nurses also were were faced with a unique ethical challenge.

The law specifies that only a physician can legally initiate the process designed to allow a patient to take his or her own life. But what about the nurse’s role in that patient’s care? Nurses are often the ones in close, day-to-day contact with patients. What if they receive a request for information about the patient’s rights under the new law? And what if the nurse’s personal beliefs conflict with the patient’s wishes? Must he or she participate in carrying out the patient’s request? What kind of information should the nurse be able — or required —to provide?

Those are some of the issues the Portland-based Oregon Nurses Asssociation (ONA) attempted to resolve with a position paper and guidelines for nurses on the new law. (See guidelines, inserted in this issue.)

"The guidelines were designed to address the practice concerns of nurses who choose to be involved with patients who use this law and those who choose not to be involved in that care," says Susan King, the ONA staff member who worked with the organization’s 20-member task force to develop the guidelines.

"The task force also wanted to assert the patient’s self-determination as the primary guiding principal for any nurse’s approach," she adds. "As with the general public, ONA members are not universally supportive of the Death with Dignity Act."

The task force comprised 20 nurses from acute, long-term, and community-based care areas, she says. Although the task force referred to documents and position statements from the Ameri can Nurses Association (ANA) in Washington, DC, and other organizations, it mostly relied on information from its Code for Nurses and on personal experience in caring for terminally ill patients, King adds.

"When we started getting into this, we found that almost every professional [nursing] association in the world said, Don’t participate in physician-assisted suicide,’" says Bonnie Driggers, RN, assistant hospital director in the oncology unit at Oregon Health Sciences University (OHSU) Medical Center in Portland and a member of the task force.

"That’s fine for [those organizations]. But this is now legal here. The patient is making a legal request, and we have to give advice to the nurses," she says.

The key issues involve the nurses’ responsibility to ensure patients receive adequate information about all available treatment options; main - tain patient confidentiality; and have a clear understanding of their obligations to patients under the law. They also must be able to limit their role in the assisted suicide of a patient if assisted suicide conflicts with their own moral code, Driggers explains.

Participation’ broadly defined

In keeping with the policy of the ANA and other national and international organizations, the ONA adopted a definition of participation in assisted suicide that precluded the nurse from actually giving the lethal medication to the patient.

"The word participate in the ONA document really looks at administering the medications, although the law really does not allow that," Driggers notes. The act specifically states that patients themselves must take the medication.

The ONA guidelines are able to guide nurses in their "participation" in a patient’s care and still bar them from participating in the actual assisted suicide.

The ONA guidelines permit nurses to discuss treatment options, including options under the new law, with patients. At OHSU, however, the policy is to have a single person designated to advise patients on these issues after they make a request for information about the Death with Dignity Act, Driggers says.

"The person we have designated is somebody who knows how to advise patients on how to talk to their physicians about it, who knows what our system policies and procedures are, and somebody who also can coach physicians about their rights and responsibilities when they receive a request," she explains.

This policy eliminates the prospect of a nurse who is opposed to assisted suicide being placed in the position of offering advice to the patient. "Our whole focus is to ensure that patients get hooked up with someone who is willing to talk to them about what the law says, explore the meaning behind their request, and help them in coming to a decision."

This method also helps protect the patient’s confidentiality if only one person deals with the request after it is made, she adds. "I recently had a provider come up to me and say that we had had a request. I asked how it came to her attention, and she said a float nurse had been working with a patient, the patient had made a request for information. The nurse then contacted the appropriate person in our system. She knew the policy and that she could not talk to the patient and she could not talk to anyone else about that situation."

One of the complicated areas the guidelines clarify is what a nurse should do if a patient requests assisted suicide and the nurse feels he or she morally cannot participate in that act. "We have a conscienctious practice policy here at OHSU," notes Driggers. "It applies in the area of abortion, assisted suicide, and withdrawal of life support. We state that any physician or provider has the right to say, I cannot participate in this procedure.’ The policy is procedure-based, not patient-based, she emphasizes.

The ONA document stressed that nurses were not permitted to abandon the care of the patient, but they did not have to be the clinician responsible for withdrawing life support or attending when death under assisted suicide occurs, Driggers says. "We do allow a transfer of care if the clinicians are opposed," she notes. "The document answers the questions of What do I have to do?’ What can I do?’ and What can’t I do?’"

Looking ahead, the Oregon Board of Nursing is working on developing nursing curriculum that deals with assisted suicide, says Driggers, who is also on a board task force examining these issues. "We will have to make people understand what the regulatory implications of assisted suicide are. "For example, what can a nurse be sanctioned for?" she asks.

The board also is focusing on enhancing the state’s curriculum on end-of-life care. "That is truly needed, and I think that even nurses across the country believe that is needed," she notes.

Sources

Bonnie Driggers, RN, Oregon Health Sciences University Medical Center, 3181 S.W. Sam Jackson Park Road, Portland, OR 97201-3098.

Susan King, Oregon Nurses Association, 9600 S.W. Oak St., Suite 550, Portland, OR 97223-6599.