Tuesday, January 3, 2012

When Nurses Are Asked to Hasten Death

With debate building in Massachusetts over Dignity 2012, the ballot effort to legalize assisted suicide, I’m increasingly interested in how the movement to endorse medical assistance in hastening death is playing out elsewhere.
Twitter yesterday drew my attention to a commentary, “The Royal College of Nursing guidance on responding to a request to hasten death,” in the December 2011 edition of the International Journal of Palliative Nursing.
In Summer 2009, the Royal College of Nursing in the UK adopted a neutral position on assisted suicide, which is illegal in the UK. All things considered, it was a bold move, as a few months later the UK Director of Public Prosecutions stated that likelihood of prosecution for assisted suicide increases for health care professionals. 
This past fall, the RCN published related guidelines for when a patient asks for assistance in hastening death, and now nurse Sarah Riches has written an insightful critique of the guidelines.
In most literature I’ve seen related to the end-of-life conversation, the nurse’s role is misleadingly marginalized and any “important” conversation is between doctor and patient. In the 2010 PBS Frontline documentary “Facing Death,” the nursing role was negligible. But while this might be a reflection of literature and media, it’s hardly a reflection of the reality of care.
As Riches and the RCN guidelines both note, nurses and nursing assistants spend the most time with patients, and the most time in conversation with them. Compared with physicians, the nurse-patient relationship suffers less from of a power imbalance, and an empowered patient seems more likely to state true wishes. So communicating about end-of-life issues can be as important as any other nursing skill.
In her commentary, Riches, the nursing director at St. Giles Hospice in Whittington, England, cites strong public support for the right of terminal patient to choose assisted death, and a preference for euthanasia over PAS. And yet, as the RCN guidelines note prominently, euthanasia and assisted suicide are illegal throughout the UK (which is how UK doctors want them to stay: http://pmj.sagepub.com/content/26/1/23.abstract.)
Riches faults the RCN guidelines for focusing on assisted dying rather than placing that conversation within the crucial and broader discussion of end-of-life issues -- where the need for communication skills is great. 
Within that criticism can be found, perhaps, the root of a significant problem in specialized care in the US -- where discussing dying with patients is something of a dying art. Surgeons don’t like to discuss end of life care, according to the Annals of Surgery; oncologists also tend to stress the positive. Meanwhile, reimbursement for end-of-life conversations is somehow controversial, and palliative care (the specialty known for its communication skills) is often a last resort.
With the MOLST advance directive and assisted suicide the subjects of broad public debate in Massachusetts, UK nurse Riches’ point is a timely one: Terminal patients deserve a more skilled discussion of end of life issues, with how to address assisted suicide just one aspect of it. 
The RCN guidelines are a useful resource for a difficult conversation: 

Riches’ commentary:

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