Assisted Suicide

1. Assisted Suicide Shenna Meredith, RN

2. Objectives • To understand the definition of assisted suicide. • To understand the law as well as the ANA perspective in regards to assisted suicide. • To be able to define the difference between palliative care and assisted suicide. • To gain knowledge of nursing’s role in patient care and ethics in regards to assisted suicide.

3. Definitions • Physician Assisted Suicide • Suicide is the act of taking one's own life. In assisted suicide, the means to end a patient’s life is provided to the patient (i.e. medication or a weapon) with knowledge of the patient's intention. • Active Euthanasia • Euthanasia, often called "mercy killing", is the act of putting to death someone suffering from a painful and prolonged illness or injury. Active euthanasia means that someone other than the patient commits an action with the intent to end the patient's life, for example injecting a patient with a lethal dose of medication. • Palliative Care • Care designed to provide relief from pain and suffering rather than to cure. (ANA, 2012)

4. Assessment of the Healthcare Environment • The fact that assisted-suicide is illegal in the State of Michigan does not mean that it is not still a controversial issue • Many medical professionals will attest that assisted-suicide does take place (Meier, et al., 1998). • There is a lack of knowledge in regards to the difference between assisted-suicide and palliative care (Arnstein & Robinson, 2011).

5. Legal & Ethical Implications Legal • Illegal in all states except • Oregon • Washington • Montana • Each state has its own legal precedent and ramifications • Michigan law states; • 750.329a Intent to assist individual in suicide; prohibited conduct; felony; exception; effect of common law offense. Sec. 329a. • (1) A person who knows that an individual intends to kill himself or herself and does any of the following with the intent to assist the individual in killing himself or herself is guilty of criminal assistance to the killing of an individual, a felony punishable by imprisonment for not more than 5 years or a fine of not more than $10,000.00, or both: • (a) Provides the means by which the individual attempts to kill himself or herself or kills himself or herself. • (b) Participates in an act by which the individual attempts to kill himself or herself or kills himself or herself. • (c) Helps the individual plan to attempt to kill himself or herself or to kill himself or herself. • (2) This section does not apply to withholding or withdrawing medical treatment. • (3) This section does not prohibit a prosecution under the common law offense of assisting in a suicide, but a person shall not be convicted under both this section and that common law offense for conduct arising out of the same transaction(Legislative Council, State of Michigan, 2009). Ethical • ANA – • The American Nurses Association (ANA) believes that the nurse should not participate in assisted suicide. Such an act is in violation of the Code for Nurses with Interpretive Statements (Code for Nurses) and the ethical traditions of the profession. Nurses, individually and collectively, have an obligation to provide comprehensive and compassionate end-of-life care which includes the promotion of comfort and the relief of pain, and at times, foregoing life-sustaining treatments (ANA, 1994). • AMA – • Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks (AMA, 1996)

6. Resources • Nurses can look to the ANA for professional ethical standards, expectations, and support (ANA, 1994). • Ethics committees within hospitals • Palliative care nurses for education and information

7. Quality & Safety Issues • Patient rights and safety • Limits and boundaries • Patient centered care • Offer palliative • Legal ramifications for RN, MD, and organization

8. Root Cause Analysis • Hospitals should have in place strict policy guiding RN’s handling of assisted-suicide within Michigan. • Due to it’s legal ramifications, discovering “why” it would take place, should not occur.

9. Nursing Theory • Peaceful End of Life Theory • Cornelia M. Ruland & Shirley M. Moore • Patient & family focused • Process is defined by those actions which promote positive outcomes • Being free from pain • Experiencing comfort • Experiencing dignity and respect • Being at peace • Experiencing a closeness with significant others and those who care

11. Secondary Theory • Principlism • Beauchamp & Chrildress • Four main principles • Autonomy • Non-Maleficence • Beneficence • Justice • Three rules • Substantive rules • Rules of truth telling, confidentiality, privacy, fidelity, and rules pertaining to the allocation and rationing of health care, omitting treatment, physician-assisted suicide, and informed consent • Authority rules • Who may or should perform actions • Procedural rules • Procedures to be followed (Pennsylvania State University, n.d.)

12. Inferences and Implications/Consequences Assisted-suicide is a highly debated topic in the United States (Gastmans, Lemiengre, & Dierckx de Casterle, 2006). • Legal now in three states, legislative initiatives to legalize assisted-suicide in other states is currently pending (ProCon.org, 2012). • A number of professionals argue that assisted suicide should be a patient’s choice and abides by the patient’s right to autonomy (Lachman, 2010). • Others argue, including both the ANA and AMA, that abiding by a patient’s request for assisted-suicide strictly goes against medical ethics and the obligation to do no harm (Pies, 2012). • In Michigan it is Illegal to participate in assisted-suicide (Legislative Council, State of Michigan, 2009).

13. Palliative Care: An Alternative • Provides care to patient’s with serious illnesses at the end-of-life • Symptom management • Pain relief • Stress relief • Comfort • The ANA states that “withholding or withdrawing life-sustaining therapies or risking the hastening of death through treatments aimed at alleviating suffering and/or controlling symptoms are ethically acceptable and do not constitute assisted suicide” (ANA, 1994).

14. Quality & Safety Improvements • Although assisted-suicide remains a highly controversial issue, recommendations include • Follow the ANA Code of Ethics for Nurses • Develop a hospital wide education initiative regarding the indication and utilization of palliative care • Implement an ethics committee and create a organizational plan for dealing with assisted-suicide

15. QSEN • Patient-centered care • Work with patients to create plans of care that are defined by the patient • Work to address ethical and legal issues related to patients’ rights to determine their care • Support patients in their decisions even when the decision conflicts with personal values • Safety • Use best practices and legal requirements to report and prevent harm • Encourage a positive practice environment of high trust and high respect (AACN QSEN Education Consortium, 2012)

16. ANA • Assisted-suicide can have a direct correlation into a number of ANA nursing standards. • Standard # 7 - Ethics • Contributes to resolving ethical issues • Delivers care in a way that preserves and protects patients autonomy, dignity, and rights • Uses the ANA Code of Ethics for Nurses as a guide to practice by. • Standard # 15 - Resource Utilization • Utilizing hospital based ethics board and members • Palliative care nurses • Standard # 13 - Collaboration • Communicates with patient, family, and healthcare providers regarding patient care and the nurse’s role in providing that care. • Facilitates an interdisciplinary process with other members of the healthcare team. (American Nurses Association, 2010).

17. Conclusion • Although legal in 3 states, assisted-suicide remains an highly controversial ethical issue within the medical field. • ANA at this time does not support assisted-suicide. • Palliative care, including pain and comfort management is ethically endorsed by the ANA

18. References AACN QSEN Education Consortium. (2012, September 24). Graduate level QSEN competencies. Retrieved from AACN: http://www.aacn.nche.edu/faculty/qsen/competencies.pdf AMA. (1996). Opinion 2.211 - Assisted suicide. Retrieved from American Medical Association: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion2211.page? American Nurses Association. (2010). Nursing scope and standards of practice. Silver Spring, MD: Nursesbook.org. ANA. (1994, December 8). Assisted suicide. Retrieved from Nursingworld.org: http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements/prtetsuic14456.html ANA. (2012). Assisted suicide. Retrieved from Nursingworld.org: http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements/prtetsuic14456.html

19. Arnstein, P., & Robinson, E. (2011, August). Is palliative sedation right for your patient? Nursing 2011, 50-54. Gastmans, C., Lemiengre, J., & Dierckx de Casterle, B. (2006). Role of nurses in institutional ethics policies on euthanasia. Journal of Advanced Nursing, 54(1), 53-61. Lachman, V. (2010). Physician-assisted suicide: Compassionate liberation or murder? Medical Sugical Nursing, 19(2), 121-125. Lautrette, A., Ciroldi, M., Ksibi, H., & Azoulay, E. (2006). End of life family conferences: Rooted in the evidence. Critical Care Medicine, 34(11), S364-S372. Legislative Council, State of Michigan. (2009). Section 750.329a. Retrieved from Michigan Legislative Website: http://www.legislature.mi.gov/ (S(yhco5xuezn5zve45cowuuq2l))/mileg.aspx?page=getObject&objectName=mcl-750-329a

20. Meier, D. E., Emmons, C.-A., Wallenstein, S., Quill, T., Morrison, R., & Cassel, C. K. (1998). A national survey of physician-assisted suicide and euthinasia in the united states. The New England Journal of Medicine, 338(17), 1193-1201. Pennsilvania State University. (n.d.). Theoretical approaches to health care ethics. Retrieved from PennState: The College of Health & Human Development School of Nursing: http://www.personal.psu.edu/dxm12/n458/theoretical_approaches.htm Pies, R. (2012). Physician-assisted suicide: Why medical ethics must sometimes trump the patient's choice. Retrieved from PsychCentral.com: http://psychcentral.com/blog/archives/2012/10/07/physician-assisted-suicide-why-medical-ethics-must-sometimes-trump-the-patients-choice/ ProCon.org. (2012, May 16). State laws on assisted suicide. Retrieved from ProCon.org: http://euthanasia.procon.org/view.resource.php?resourceID=000132 Sprung, C. L., Ledoux, D., Bulow, H.-H., Lippert, A., Wennberg, E., Baras, M., . . . Group, E. S. (2008). Relieving suffering or intentionally hastening death: Where so you draw the line? Critical Care Medicine, 36(1), 8-13.