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.     

An international expansion in voluntary euthanasia/assisted dying: The implications for nursing

Aim

To provide an update on the international position of assisted dying legislation and its implications for nursing policy.

Background

Assisted dying legislation has been introduced in health systems in Europe, North America and Australasia (Australia and New Zealand). Despite contributions in research literature, this remains focussed on medical practitioners, with limited acknowledgement of the need for policy development in nursing.

Discussion

There is a need for critical evaluation of this contemporary issue and the significance for nursing practice of the lack of unified nursing perspective and robust policy guidance is identified. An overview of the existing role of voluntary euthanasia/assisted dying with recent developments is provided and the resulting concerns for nurses regarding the scope of practice, role confusion and conflicting professional values is considered.

Conclusion

Despite a long history of assisted dying and the continued expansion of these practices, limited and highly variable nursing policy highlights the lack of clear guidance available to nurses. The growing inclusion of nurse practitioners and recognition of registered nurse involvement in the care of individuals on an assisted dying pathway merits clearer support from regulatory authorities and professional organisations.

Implications for nursing practice

Nurses are the most likely health professionals to be approached with questions regarding assisted dying; they are intimately involved in patient experiences and need to understand what is possible, expected and legal in terms of their scope of practice regarding assisted dying.

Implications for nursing policy

Nursing regulators and professional representatives need to provide clear policy statements and guidance identifying the nursing role and recognising where protections and support are necessary.     

Euthanasia and assisted suicide in the Netherlands: Clarifying the practice and the nurse's role

Many people believe that euthanasia and assisted suicide are condoned carte blanche in the Netherlands. Not true. Both are formally forbidden by criminal law and can be administered only when certain procedures and criteria have been followed. Below, a look at the policies and practices regarding euthanasia and assisted suicide in The Netherlands and the role of nurses in this area.     

Medical Aid in Dying,Hastened Death,and Suicide: A Qualitative Study of Hospice Professionals' Experiences From Washington State

ContextMany jurisdictions around the world have passed medical aid in dying (MAID) laws allowing competent eligible individuals facing life-limiting illness to self-administer prescribed medication to control timing of death. These laws do not prevent some patients who are receiving hospice services from dying by suicide without assistance.ObjectivesTo explore hospice professionals' experiences of patients who die by suicide or intentionally hasten death with or without legal assistance in an area where there is legalized MAID.MethodsSemistructured in-depth qualitative interviews were conducted with 21 home hospice professionals (seven nurses, seven social workers, four physicians, and three chaplains). Thematic analysis was carried out to analyze the data.ResultsThree primary themes were identified from the interviews: 1) dealing with and differentiating between hastened death and suicide, 2) MAID access and affordability, and 3) how patients have hastened their own deaths. Analysis of these data indicates that there are some patients receiving hospice services who die by suicide because they are not eligible for, have no knowledge of, or lack access to legalized MAID. Hospice professionals do not consistently identify patients' deaths as suicide when they are self-inflicted and sometimes view these deaths as justified.ConclusionSuicide and hastened deaths continue to be an unexamined cause of death for some home hospice patients who may have requested MAID. Open communication and increased education and training is needed for palliative care professionals regarding legal options, issues of suicide, and suicide assessment.     

Medical Assistance in Dying in Canada: Focus on Rural Communities

The 2015 Carter v Canada (Attorney General) case radically changed end-of-life care in Canada. This groundbreaking decision legalized physician-assisted suicide for competent adults who meet certain clinical criteria and who consent to their termination of life. The federal government then passed its legislative response, Bill C-14, to change the Criminal Code and legalize medical assistance in dying. Since Bill C-14 was enacted, the health care community has struggled to ensure that its implementation occurs in a legally compliant, patient-centered manner. This article focuses on the challenges of this new law for nurse practitioners, especially those in rural and remote communities.     

The Relationship of Palliative Care With Assisted Dying Where Assisted Dying is Lawful: A Systematic Scoping Review of the Literature

ContextA central approach of palliative care has been to provide holistic care for people who are dying, terminally ill, or facing life-limiting illnesses while neither hastening nor postponing death. Assisted dying laws allow eligible individuals to receive medically administered or self-administered medication from a health provider to end their life. The implementation of these laws in a growing number of jurisdictions therefore poses certain challenges for palliative care.ObjectivesTo analyze the research literature about the relationship of assisted dying with palliative care, in countries where it is lawful.MethodsA five-stage scoping review process was adapted from the Joanna Briggs Institute. Data sources searched through October 2018 were MEDLINE, CINAHL, PsychINFO, SCOPUS, and ProQuest dissertations and theses, with additional material identified through hand searching. Research studies of any design were included, but editorials or opinion articles were excluded.ResultsAfter reviewing 5778 references from searches, 105 were subject to full-text review. About 16 studies were included: from Belgium (n = 4), Canada (n = 1), Switzerland (n = 2), and the U.S. (n = 9). We found that the relationship between assisted dying and palliative care practices in these locations took varied and sometimes combined forms: supportive, neutral, coexisting, not mutually exclusive, integrated, synergistic, cooperative, collaborative, opposed, ambivalent, and conflicted.ConclusionThe studies in this review cast only partial light on challenges faced by palliative care when assisted dying is legal. There is pressing need for more research on the involvement of palliative care in the developing practices of assisted dying, across a growing number of jurisdictions.     

Euthanasia and assisted suicide in Dutch hospitals: the role of nurses

Aim. To report a study on the role of nurses in euthanasia and physician‐assisted suicide in hospitals, conducted as part of a wider study on the role of nurses in medical end‐of‐life decisions. Background. Issues concerning legislation and regulation with respect to the role of nurses in euthanasia and physician‐assisted suicide gave the Dutch Minister for Health reason to commission a study on the role of nurses in medical end‐of‐life decisions in hospitals, homecare and nursing homes. Method. A questionnaire was sent in 2003 to 692 nurses employed in 73 hospital locations. The response suitable for analysis was from 532 (76·9%) nurses. Data were quantitatively analysed using spss version 11.5 for Windows. Results. In almost half of the cases (45·1%), the nurse was the first with whom patients discussed their request for euthanasia or physician‐assisted suicide. Consultations between physicians and nurses quite often took place (78·8%). In several cases (15·4%), nurses themselves administered the euthanatics with or without a physician. It is not self‐evident that hospitals have guidelines concerning euthanasia/physician‐assisted suicide. Conclusions. In the decision‐making process, the consultation between the physician and the nurse needs improvement. In administering the euthanatics, physicians should take responsibility and should not leave these actions to nurses. Guidelines may play an important role to improve the collaboration between physicians and nurses and to prevent procedural, ethical and legal misunderstandings. Relevance to clinical practice. Nurses in clinical practice are often closely involved in the last stage of a person's life. Consequently, they are often confronted with caring for patients requesting euthanasia or physician‐assisted suicide. The results provide relevant information and may help nurses in defining their role in euthanasia and physician‐assisted suicide, especially in case these practices should become legalised.     

Nursing older dying patients: findings from an ethnographic study of death and dying in elderly care wards

Nursing older dying patients: findings from an ethnographic study of death and dying in elderly care wards Background and aim. The aim of the study was to explore the experiences of dying patients and nurses working in three elderly care wards focusing on the management of care for dying patients. The majority of patients who die in hospital are over the age of 65 and evidence suggests that three fifths are over the age of 75. Older patients pose tremendous problems and challenges to nurses and doctors regarding the provision of good terminal care, particularly in relation to developing effective communication. METHOD: An ethnographic research design was chosen. The research sample consisted of 74 patients, 29 nurses and 8 physicians. The principle data collection methods were participant observation and semi-structured interviews. All respondents were interviewed following a period of observation on each of the ward areas. The data obtained from participant observation were then used to structure the interview questions. The purpose of asking questions about meanings associated with observational material was to evaluate the extent to which convergence or divergence of the data was taking place. FINDINGS: The findings demonstrate that the care of older dying patients was defined by a lack of 'emotional engagement' with the patient and the institutionalized nondisclosure of information about death and dying. The study raises issues concerning the lack of effective communication about terminal diagnosis and the strategies used by nurses and doctors for disclosing information about death and dying. The findings suggest that although nurses provide individual care to dying patients, much of this was aimed at meeting patients' physical needs. Nurses reported psychosocial aspects including spiritual and emotional care to be important, although there was little evidence of them being orientated towards this in practice. CONCLUSION: The indicative conclusions from this study suggest that terminal care for some elderly patients remains hampered by a reluctance of nurses and doctors to be more open in their communication about death. It would appear that hospital culture and the mores, beliefs and ideologies that emanate from the biomedical model, significantly shape the experiences of older dying patients.     

Living with dying: a hermeneutic phenomenological study of the work of hospice nurses

Aims. (i) Explore the meaning of comfort care for hospice nurses. (ii) Provide an understanding of how this work is pursued in the hospice setting. (iii) Examine the means by which hospice nurses provide comfort to hospice patients. Background. The concepts of ‘comfort’ and ‘comfort care’ have long been a subject for examination by nurse researchers. The paper provides an overview of selected, relevant literature in this area. The methods used by nurse researchers have almost always been qualitative, and have focused on the meaning of nursing care for dying patients, from both nurses’ and patients’ perspectives. Design and methods. The paper reports a hermeneutic phenomenological study of the work of 15 hospice nurses based in one hospice in the north of England. Sampling was purposive, and data were collected by means of semi‐structured interviews. A reflective diary was also kept. The interpretation of data was guided by phenomenological and hermeneutic methodology. Results. The nurses interviewed spoke openly about their experiences of working with hospice patients. They saw the relief of suffering through ‘comfort care’ as an important element of their work. The findings are presented under three thematic headings: ‘Comfort and relief’, ‘Peace and ease’ and ‘Spirituality and meaning’. Conclusion. Hermeneutic phenomenology is an important method for uncovering the complex realities of nursing work. The nurses’ perspectives on ‘comfort care’ they offer to patients were revealed by the data presented here, which were interpreted to offer a unique perspective on this type of nursing work. Relevance to clinical practice. These findings offer insights to nurses in both hospice and other settings; they give a number of perspectives on the nature of ‘comfort care’ and the meanings attached to it by experienced hospice nurses’.     

Inducements for medical and health research: issues for the profession of nursing

Aims and objectives. Inducements, incentives, reimbursements and payment to subjects for participation in research projects raise many practical, professional and philosophical issues for nurses. Nurses are enjoined, either formally as research co‐participants or informally as patients’ professional carers, in any research which involves their patients. This role inescapably brings significant ethical obligations, which include those of bioethical audit. Background. A review of current international guidelines on reimbursement recommendations indicates that researchers select one of several paradigms which range from the ‘commercial market model’ of supply and demand to that of pure un‐reimbursed altruism. In this latter, volunteers not only give their bodies and emotional commitment, but also sacrifice their time and convenience. Inducement is defined as the provision of resources or rewards which exceed the ‘resource neutral’ compensation for legitimate expense. If potential volunteers are truly free to make an informed choice to participate in research, no ethical compromise exists if inducements are offered; but by so doing both the research team and the volunteer patients have shifted the ethos of their research from caritas and altruism to one of a simple commercial relationship. Conclusions. Inducements are inappropriate when offered to those who are ‘ethically captive’ in the sense that autonomy of choice may be compromised. Relevance to clinical practice. In contemporary nursing practice, research involvement is both frequent and desirable. A perspective of current debate about inducements for volunteering, including legal and ethical issues, empowers nurses to protect the patients or clients in their care.     

Family Caregivers' Reflections on Experiences of Assisted Suicide in Switzerland: A Qualitative Interview Study

Context

Thousands of family members worldwide are annually involved in assisted dying. Family participation in assisted dying has rarely been investigated and families' needs typically are not considered in assisted dying legislation and clinical guidelines.

将志愿者机制引入城市贫困人口护理援助体系的构想

城市贫困人口的健康问题已经成为政府和社会普遍关注的重大问题。护理援助体系的建立是利用社会民间资源对城市贫困人口实施救助的有效途径。引入志愿者机制,可实现“一助一”结对服务,普及专科防治知识,保障城市贫困人口得到持久的护理援助。     

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.

A review of developments in medical termination of pregnancy

Aim. This literature review aims to supplement guidelines by providing an overview of recent evidence relevant to medical termination of pregnancy. Background. Termination of pregnancy is available to women in the UK within legal parameters. Although guidelines form a strong body of evidence on which nurses and midwives can base their practice, there is a need to supplement them with up‐to‐date robust research findings. Method. A systematic search of the literature with high sensitivity and low specificity was undertaken on five databases using medical subject headings (MeSH) terms including (medical) induced abortion, therapeutic abortion and termination of pregnancy. Results. The literature search revealed articles under the following headings: The importance of choice for the women involved the need for the optimal medication type, dose, route and interval between stages one and two, and the optimum place for medical termination to take place. Conclusion. It was found that women attach a great deal of importance to the opportunity to choose their method of termination. The first stage of mifepristone is now a standard practice and an optimum dose has been determined. Several studies examined misoprostol used in the second stage of medical termination. There was some evidence for repeated doses of misoprostol, particularly in later gestation, with conflicting evidence on the optimal route. There were some grounds for reducing the interval between stages. Consideration should be given to home medical termination based on individual circumstances and choice. Gestation and previous obstetric history is an important factor to take into account when determining optimal regimen. Relevance to clinical practice. The number of medical termination of pregnancies performed has risen in recent years together with the nurses’ involvement. As new research is published, it is imperative that nurses adapt to base their involvement on the best available evidence.