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ADVANCE Perspective: Nurses

The Right or the Duty to Die: Making the Case for Physician-Assisted Suicide

Published May 5, 2014 2:36 PM by Guest Blogger

By Susanne Marie Johnson, BSN, RN

In February 2013, Barbara Mancini of Philadelphia was arrested and subsequently charged with a felony of assisted suicide. The prosecution asserts Mancini provided her 93-year-old and terminally ill father, Joe Yourshaw, with the bottle of morphine that allowed him to take a lethal dose in an attempt to end his life.

Mancini’s father suffered from at least two end-stage diseases and was under hospice care in his Pottstown home. Ms. Manicini maintains that she provided her father with the morphine because he had requested it in an effort to relieve his own suffering. Despite Ms. Mancini’s assertion that her father would not want further treatment, Mr. Yourshaw was transferred to a local hospital, resuscitated, and given even more morphine for his pain after his hospice nurse called 911. He would die four days later.

If Pennsylvania and other states had legislation permitting physician-assisted suicide (PAS), Mr. Yourshaw might have died comfortably at home, surrounded by those he loved, feeling secure in the knowledge that he did not have to succumb to his diseases but could assert his right to autonomy as a patient and leave this world of his own accord.

The Netherlands has legally allowed physician-assisted suicide since 1992. In the U.S., Oregon made physician-assisted suicide legal in 1997 when voters passed the Death With Dignity Act (DWDA) and Washington passed similar legislation in 2009. The DWDA act permits a mentally competent and terminally ill individual who is over the age of 18 and a citizen of the state of Oregon to request a lethal dose of medication (usually an oral dose of a barbiturate) from their physician for the purpose of ending their life.

In order for a patient to be considered eligible to participate in the act, they must also meet the following criteria:

1. The patient must make two verbal requests separated by a period of at least 15 days to their attending physician .
2. The patient must also make a written request to their attending physician in the presence of two witnesses.
3. An attending and consulting physician must then confirm the patient’s diagnosis and prognosis and whether or not the patient is capable of making healthcare decisions for themselves.
4. If the patient’s judgment is believed to be impaired either by psychiatric condition or coercion, the patient must be referred for psychological examination.
5. The attending physician must educate the patient about alternatives including, but not limited to, palliative care, hospice care, and pain control.
6. The attending physician must request, but must not require, that the patient notify their next-of-kin of the request for the prescription. Patients may retract their request at any time.
7. Physicians must report all requests for prescriptions of lethal medications to the Oregon Health Authority and pharmacists must be notified if the prescribed medication is used.

The right to die is not the same as the duty to die. The DWDA is not a tool to advocate for the removal of life-prolonging treatments or devices. Many detractors of the DWDA have asserted that this type of legislation smacks of health care rationing and will likely prevent the terminally ill in vulnerable populations such as the poor, the under-educated, and those without health insurance from receiving palliative care and hospice services. The Oregon Health Authority makes available to the public extensive yearly reports regarding compliance with the Act, the number of individuals who request prescriptions, and the subsequent number of deaths of individuals that occur from use of the obtained prescriptions.

According to the 2013 report, 115 individuals obtained prescriptions for lethal medications, but only 77 individuals died as a direct result of using those prescriptions. Supporters of the DWDA maintain that the aim of legalizing PAS is strictly to empower the terminally-ill patient; to provide them with a sense of control over the circumstances of death, to diminish their feelings of dependence on others, to alleviate the fear of dying with uncontrolled symptoms such as intractable pain and loss of bowel/bladder control, and to allow for better preparation for death. In fact, current literature indicates that those who most often use the DWDA are wealthy and highly educated. Still more opponents of PAS believe that it would become a stand-in for quality EOL care and that patients will not be adequately informed by their physicians of other options for symptom management, pain control, and hospice services.  

There is still a widely held belief that access to quality palliative care and hospice services will fail to improve if patients have the option to take their own life. Oregon’s DWDA clearly stipulates that any patient requesting a prescription for lethal medication must be informed of alternative therapies and options by their physician to avoid this specific conflict. Family members of those who chose PAS actually noted that their loved ones had greater symptom control, better energy and interaction with their environment, and seemed more prepared for death according to those who participated in a study using a 33-item measurement tool of the quality of death and dying.

Physician-assisted suicide and the Oregon Death With Dignity Act continue to be controversial ethical and moral topics within healthcare and the U.S. legislature. As we move toward providing patients with greater healthcare options in the U.S. through the Affordable Care Act, it seems that we must also provide patients with a greater variety of options at the end of life, a time when choice and autonomy may be most important. Physician-assisted suicide in no way detracts from the care that terminally ill patients receive. Instead, physician-assisted suicide may be the intervention that most meets patients’ desire for increased control in situations where they are afforded very little determination in the outcome of their illness.

References can be accessed at www.advanceweb.com/Nurses.

Susanne Marie Johnson is on staff at Hospital of the University of Pennsylvania and a graduate student in the Family and Community Health Nurse Practitioner program with a focus on Palliative Care at the University of Pennsylvania School of Nursing.  

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