Inherent in nursing practice is the belief of a basic respect for human life conjoined with the moral obligation to be a patient advocate. As advocates, nurses face moral, ethical, and legal issues on a daily basis. This special issue of the Journal of Gerontological Nursing will help the reader explore this advocacy role in a continually evolving area, end-of-life decision making. The advocacy roles for the nurse that are discussed in this issue include assuring that advance directives and living wills are carried out according to the client's expressed wishes (Perrin), working with the client with altered decisional capacity in making determination regarding advance directives (Mezey, Mitty, and Ramsey), securing and monitoring adequate pain control for the dying client (Kazanowski), and helping the family to better understand what is involved in the dying process (Goetschius). Nurses may also be confronted by the client who requests assistance with suicide or euthanasia. Historical background and a literature review will help the reader better frame this moral issue for themselves and their profession (Matzo).
Assisted suicide and patient-requested euthanasia are two separate kinds of acts for a health care provider to potentially be involved in. Assisted suicide is defined as providing, at the patient's request, the means for them to end their own life. Patientrequested euthanasia is an active behavior on the part of the health care provider to administer medications with the express intent of ending the patient's life.
In contemporary American society, assisted suicide and patientrequested euthanasia for older adults may be less negatively perceived than is generally recognized. Under some circumstances, people may even regard assisted suicide and patient-requested euthanasia as desirable solutions to very serious health problems affecting some older people. A number of contemporary developments suggest the possibility of widespread popular sympathy for assisted suicide and patient-requested euthanasia among the elderly. One example is the fact that physician assisted suicide in Michigan has received a great deal of press coverage without major negative societal outcry.
It is important to note that assisted suicide was considered illegal until March 6, 1996 when the 9th U.S. Circuit Court of Appeals ruled that the Washington State ban on assisted suicide was unconstitutional under the right to privacy. This ruling is expected to be appealed to the Supreme Court. On April 2, 1996 the Second U.S. Circuit Court of Appeals struck down two New York laws making assisted suicide illegal. In this case, it was ruled that prohibiting a dying person to get assistance with dying was irrational and unlawful discrimination because other tenninally ill persons are allowed to disconnect life support systems when they are ready to die.
Morality, laws, technology, and attitudes toward death are evolving very rapidly compared with the past twenty years. With this evolution comes pressure on lawmakers to either legalize assisted suicide or actively prosecute those health care providers who are involved. Those who support legalizing assistedsuicide point out that there is a gap between the existing law and actual medical practice. Those against legalization fear what acts would next be legalized if those who assist suicide are not prosecuted.
Also pertinent is the increasing emphasis on advance directives through which older people and Medicare recipients provide instructions concerning the use of life sustaining methods when they are no longer capable of making decisions for themselves. The thrust of this movement is to authorize health providers to withhold use of life-sustaming technology under certain conditions, thus allowing the older person to die. The conscious rejection of use of certain life sustaining strategies is not suicide; however, it does reflect a qualified view about sustaining life and invites questions about the possibility that assisted suicide and euthanasia might be viewed sympathetically under some circumstances.
This special issue of the Journal of Gerontological Nursing sets the stage for the reader to further explore end-of-life issues. The end of life is not just one more stage of life; as the final life stage, the nurse is entrusted with an incredible obligation and responsibility. It is our hope that the reader will use the information in this issue to spark debate among colleagues and to further explore their role of advocate when the client is most vulnerable.