Last month palliative care nurse Annmarie Hosie spoke at a seminar on palliative care and assisted dying organised by MercatorNet at the New South Wales Parliament building. This is an abridged version of her presentation.
By Annmarie Hosie
Today my brief is to talk about the adverse impact that legalising euthanasia would have on nurses and care of patients with a terminal illness. I am speaking on this topic in a personal capacity, as a former palliative care clinical nurse and now as a researcher.
To begin, allow me to discuss some basic concepts.
What is “euthanasia”? It is any action (or omission) that intends to cause the death of a person, whatever the circumstances and whatever the alternative terminology.1
What is healthcare? Healthcare promotes optimal health and development throughout the human lifespan, cures illness, heals, cares, comforts and alleviates suffering.
Nurses are intimately involved in healthcare of people, and work closely with medical practitioners and in interdisciplinary teams. According to our international code of ethics2 nurses have four fundamental responsibilities: “to promote health, prevent illness, restore health and alleviate suffering”. Palliative care focuses on relief of suffering, but this focus doesn’t negate the other responsibilities. Nurses care for people in the last year of life in hospitals, private homes, aged care facilities, prisons and group homes for people with disabilities.
With the exception of prisons, I have cared for people in all of these settings, and in 30 years, I don’t recall a single person requesting physician-assisted suicide.
Legal euthanasia would lead to confusion about ethical palliative care
If euthanasia were legal, nurses would understandably become confused about the fundamental and long-accepted principles of healthcare. These include: beneficence (to do good); non-maleficence (to do no harm); justice (fairness); and autonomy (choice).
If euthanasia were legalised, how should a nurse react if a person expresses a suicidal intent, or commits suicide, especially someone with a terminal illness? Preventing suicide is an integral responsibility of healthcare as governments are fully aware.
A nurse (indeed, any healthcare professional) who recognizes that a patient is suicidal is expected to intervene for their safety and to maintain life, guided, in New South Wales, by Suicide Risk Assessment and Management Protocols.3 Nurses have a responsibility to act to protect the life of a person who has attempted suicide, and to report suicide deaths to the coroner.
Both “voluntary assisted” death and suicide mean the same thing: to intentionally end one’s own life. If euthanasia were legal, some laws and some healthcare policies would clash.
What would a nurse do if caring for someone who has a lethal dose of medication in their possession and communicates a plan to use it?
What would a nurse do if called to the house of someone who was dying and found that the person was dying in distress after ingesting a lethal dose of medication? Professionally and ethically the nurse must always act for the good of the person.
Distinguishing between palliative care and euthanasia would become more confusing if euthanasia were legal. Palliative care does not intend to hasten death,8 whereas euthanasia does. However, this distinction is not always understood, because even though the cause is different—the first being natural and the second induced—death occurs in both situations.
People eligible for assisted suicide, according to the NSW Voluntary Assisted Dying Bill (like similar bills in other states), must have a terminal illness. It’s natural to assume that many of them will be receiving palliative care. How would nurses effectively and ethically care for someone according to these two opposed approaches? How easily would the lines become blurred between ethical palliative care and intentionally causing someone’s death?
There is evidence, too, that nurses experience confusion and moral conflict with regards to euthanasia and palliative care.
A review of the literature of nurses' attitudes toward euthanasia in 20059 found that nurses felt conflicting emotions over euthanasia deaths—compassion for the patient, but also guilt, anger, fear, and involvement in an “unnatural event.” They felt that they were vulnerable and their opinions were overlooked.
Another study of the attitudes of physicians and nurses in Flanders (the Dutch-speaking part of Belgium where euthanasia is legal) and experience of palliative sedation for refractory symptoms at the end of life found that the boundary between palliative sedation and euthanasia was blurred. One nurse said: “Sedation was frequently started with the understanding: ‘If the patient is still here tomorrow, then we will double [the dose]’. That was commonplace. So in fact they often ended life, even if this was not the initial intention of the sedation.”10
By its very nature, palliative care is challenging and complex. Legal euthanasia makes this worse. Nurses tend to suppress their own beliefs about the wrongfulness of intentionally causing death so that they can remain caring for a dying patient. If euthanasia were legal, we will see increased burnout, compassion fatigue and nurses leaving the profession.11
Furthermore, how would nurses inform and reassure the fears of patients and families, who are so often very apprehensive when a referral to palliative care is made, and many likely more so, if euthanasia were legal?
Witnessing and participating in harm to patients
Euthanasia is commonly described as “just like going to sleep.” But, as a nurse, I don’t believe that giving lethal doses of medication guarantees dying would be peaceful or gentle.12
Nurses who provide palliative care frequently give patients medications for symptom management like pain, breathlessness and anxiety, using many of the same medications that are commonly used for euthanasia such as benzodiazepines and opioids.6 These medications can cause distressing side-effects even at therapeutic doses13—dizziness, dry mouth, nausea, vomiting, irritability, hallucinations, and delirium.6,14
Delirium is an acute disturbance of awareness and cognition; it is a frightening, humiliating and isolating experience.15 Some people have described it as “hellish.” Unconsciousness may not make a person unaware of delirium, only unable to verbally communicate the experience. Not everyone will be delirious during natural dying, but he or she almost certainly would be while dying of a lethal dose of medication.16,17
Other technical problems and complications reported in euthanasia and capital punishment deaths include: cardiac arrhythmias, difficulty accessing a vein, gasping, jerking, seizures, regurgitation of ingested medication, and longer than anticipated duration of dying.14,18
I’m sceptical of the argument that euthanasia techniques will become more refined with legislation and increased practice.6 Bringing about death always requires inflicting extreme physical harm.18
If euthanasia or assisted suicide were legal, nurses would witness this harm occurring to patients. It is easy to foresee that they might even be involved in helping to administer lethal doses of medication, if a patient requests their help.
The difference between a compassionate response to suffering and a merciful one
Euthanasia is sometimes referred to as “mercy killing.” This positions euthanasia as excusable, desirable, or even necessary. But it twists the real meaning of mercy.
Mercy is inspired by love and compassion, and informed by reason. Mercy requires us to use our strengths to do everything possible for the well-being of another person. Mercy results in more goodness than the person expected in the given circumstances. Mercy fulfils the purpose of healthcare to restore human dignity during sickness.
Earlier, I said that I don’t recall any person with a terminal illness expressing a wish for their doctor to help them commit suicide. A few weeks ago, a palliative care nurse colleague with more recent clinical experience than I have told me that several of her patients—who were all intelligent, well-educated and affluent—had talked to her about the option of euthanasia over the months that she cared for them. In the end, each one of her patients died naturally and peacefully, with family close by, including grandchildren playing on their beds. Each one said to her, “Thank God euthanasia isn’t legal, because if it had been, I would have taken that option.”
Those unexpectedly good last days with their families are another example of mercy.
Nurses have many opportunities to give and witness mercy to a person with terminal illness. I have seen every human emotion on the faces of people close to death: sadness, pain, fear, confusion and strain, along with peace, smiles, winks, joy, love and bliss. I remember being with young parents at the bedside of their little boy, listening to them sharing a small family joke with his grandparents just minutes before he died of a brain tumour. When they laughed, peace filled the room, and he died. It’s not what you would expect in such a situation—it wasn’t what any of us in the room expected—but it happened.
When we care for people in their natural dying and see the unexpected good that can happen during such difficulties, our own fear about death can ease. We become better at bringing peace and hope to others who are frightened about dying. As a palliative care nurse, I can honestly say I don’t fear dying or death. But I would have reason to fear being old and sick if I lived in a place where euthanasia was legal.
Rather than an effective way of relieving suffering, legal euthanasia would cause increased confusion and harm, both for and by nurses. My hope is that we will continue to aim high and strive always for merciful nursing and healthcare, and a merciful society.
Dr. Annmarie Hosie is a registered nurse and post-doctoral research fellow at the University of Technology, Sydney.
This article has been reprinted with permission and can be found at mercatornet.com/careful/view/how-euthanasia-affects-nurses/20591.
1. Sulmasy DP, Ely EW, Sprung CL. Euthanasia and Physician-Assisted Suicide. Jama. 2016;316(15):1600.
2. International Council of Nurses. The ICN Code of Ethics for Nurses. Geneva, Switzerland: International Council of Nurses; 2012.
3. NSW Government. Suicide Prevention Program. 2017; health.nsw.gov.au/mentalhealth/cg/Pages/mh-suicide.aspx. Accessed September 17, 2017.
4. Australian Commission on Safety and Quality in Health Care. End-of-Life Care. 2017; safetyandquality.gov.au/our-work/end-of-life-care-in-acute-hospitals/. Accessed September 17, 2017.
5. Radbruch L, Leget C, Bahr P, et al. Euthanasia and physician-assisted suicide: A white paper from the European Association for Palliative Care. Palliative Medicine. 2015.
6. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79-90.
7. Cohen J, Van Wesemael Y, Smets T, Bilsen J, Deliens L. Cultural differences affecting euthanasia practice in Belgium: one law but different attitudes and practices in Flanders and Wallonia. Soc Sci Med. 2012;75(5):845-853.
8. World Health Organisation. WHO Definition of Palliative Care. Vol 2011: World Health Organisation; 2002: who.int/cancer/palliative/definition/en/.
9. Berghs M, Dierckx de Casterlé B, Gastmans C. The complexity of nurses’ attitudes toward euthanasia: a review of the literature. Journal of Medical Ethics. 2005;31(8):441.
10. Anquinet L, Raus K, Sterckx S, Smets T, Deliens L, Rietjens JA. Similarities and differences between continuous sedation until death and euthanasia - professional caregivers' attitudes and experiences: a focus group study. Palliat Med. 2013;27(6):553-561.
11. Nolte AGW, Downing C, Temane A, Hastings-Tolsma M. Compassion fatigue in nurses: A metasynthesis. Journal of Clinical Nursing.n/a-n/a.
12. Stewart F, Nitschke P. The Peaceful Pill Handbook. Exit International USA; 2008.
13. Palliative Care Expert Group. Therapeutic Guidelines: Palliative Care (Version 4). Melbourne: Therapeutic Guidelines Ltd; 2016.
14. Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD, Willems DL, van der Maas PJ, van der Wal G. Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands. New England Journal of Medicine. 2000;342(8):551-556.
15. O'Malley G, Leonard M, Meagher D, O'Keeffe ST. The delirium experience: a review. Journal of Psychsomatic Research. 2008;65(3):223-228.
16. Caraceni A. Drug-associated delirium in cancer patients. European Journal of Cancer Supplements. 2013;11(2):233-240.
17. Devlin J, Fraser G, Riker R. Drug-Induced Coma and Delirium. In: Papadopoulos J, ed. Drug-Induced Complications in the Critically Ill Patient: A Guide for Recognition and Treatment: Society of Critical Care Medicine; 2012:107-116.
18. Quinlan M. "Such is Life”: Euthanasia and capital punishment in Australia: consistency or contradiction? Solidarity: The Journal of Catholic Social Thought and Secular Ethics. 2016;6(1):Article 6.
19. Shakespeare W. The Merchant of Venice, Act 4, Scene 1. 16th century; shakespeare.mit.edu/merchant/merchant.4.1.html. Accessed July 17, 2017.
20. John Paul II. Encyclical letter: Dives in misericordia of the Supreme Pontiff John Paul II on the mercy of God. 1980; w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_30111980_dives-in-misericordia.html. Accessed July 13, 2017.