The following question was asked of readers of the Journal of Gerontological Nursing;
Over the past year, how many patients have asked you to inject drags ta Intentionally and their lives? Have yaa ever infected drugs ta Intentionally end a patient's life?
In the last year, no patients have asked me to inject drugs to end their life. I have never injected drugs to intentionally end a patient's life. I have, however, given injections of Morphine Sulfate to terminal cancer patients with respirations of less than 12 per minute to alleviate pain in the dying process. Death did not occur as a result of the injections.
Cynthia M. Webb, RN
Director of Nursing
Sterling Place Nursing Home
Baton Rouge, Louisiana
I have been asked about three times. The patients all suffered from CVAs and had extensive residual effects. I never helped to end a life, only helped the families and patients deal with the death.
Denise Sheckard, BSN, RN
In the four years that I have been a home health and hospice nurse, no one has ever requested that I give them any form of drug to end their lives. Dying patients have begged that I relieve their pain or discomfort and this is, in most cases, possible. When facing a terminal illness, patients need to be reassured they may die comfortably. They often need the permission to die from family and friends, but I've never seen someone need a lethal injection to help them.
Pauline Wilder, RN, MSN
Waldo County Home Health Care
& Hospice Services
These specific events have not occurred with me. I have listened many times when patients have talked about dying and wanting to die. I can offer empathy and listen, I can explore with the patient the feeling. I can talk with other staff to seek approaches best suited for individual patients. I personally could do neither as it is wrong for me personally as well as morally and ethically wrong.
Beverly L Marks, RN, BS
Director of Nursing
In my 27 years of nursing, I have been asked on several occasions, "Can't you give me something to end all of this?" Not in the past year have I been asked this question, though patients have said they wished or wondered when it would all be over. I have not, nor would I be willing to intentionally administer a lethal dose to end a person's life.
Death, like birth and each stage of our life, is a journey to be experienced. However, patients who are dying and have pain should not be allowed to suffer needlessly. Medications are available to control pain and should not be used sparingly for fear of addiction, it does not happen in patients dying in pain. Health care providers, especially nurses, should and do advocate for adequate pain control. The pain control should be "tailored" for each individual. There are those who want control, but want to be alert and participate in every aspect of the dying process. There are those who want to be "knocked out" and have the pain controlled until they die. Each individual's wishes should be honored by health care providers but a lethal injection should not be the cause of the patient's demise.
Elizabeth Williams, RN, MS, C
Nursing Home Care Unit
Denver Department of Veterans Affairs
Neither incident has ever happened to me. However, a larger and more important issue needs to be addressed. It is the issue of irtforming patients of the devastating impact remaining on "Full Code" status has on their physical body I deal with an older, very debilitated client population. When discussing code status with them, I find many labor under an oversimplified myth about the nature and negative outcomes of CPR. When fully informed, I find most of these patients opt for a "No Code" status, saving themselves and their families from additional suffering. In my current job, nurses do not have the freedom to discuss and finalize this issue with clients. The doctor must sign an order for "No Code" status, and most are reluctant to do so. At my last job, nurses had the freedom to change code status per the client's wishes, documenting accordingly. This allowed clients in their last days to "tie up loose ends," say good-bye to loved ones, and pass away peacefully. As nurses attempting to maximize our clients' wellbeing, this issue must be addressed with timeliness and without ambivalence.
Meniti BeAi Keeth, RN, ADN
Mt. Diablo Medical Pavilion
Transift'ona/ Core Center
Numerous other readers responded to this question simply stating that they have not been asked to inject drugs to intentionally end patients' lives within the past year; nor have they ever done so.
This question was submitted by Review Panel member Marianne LaPorte Matzo, PhD, RN, CS, Professor of Nursing, New Hampshire Community Technical College, Manchester, New Hampshire. Dr. Matzo's comments follow.
Why do some people seek assisted suicide or euthanasia? One reason is the fear of death (Voluntary Euthanasia Society, 1992), or the fear of the state of death or non-existence). Also cited is the fear of the process of dying, or the agony of the transition to that state, or the fear of decline and loss of control. Some fear the cost of dying that can impoverish a family. Few insurance companies pay 100% of a hospital bill and many place dollar limits on services or demand high co-payment. Loss of personal identity often characterizes the end stage of terminal illness (Battin, 1991); the individual may wish to refuse to endure the final stages of deterioration that may come before death.
A paradox exists in the practice of medicine in that much can be cured, but everyone must die. The United States has a sophisticated medical system with a life expectancy of greater than age 70. It is also in the fourth stage of epidemiologie transition which is that stage of societal development where the major cause of death is not acute parasitic or infectious diseases but rather degenerative disease characterized by a late, slow onset and degenerative decline (e.g., cancer) (Battin, 1991).
Cancer is the second leading cause of death in the elderly and accounts for 21% of the deaths (23% men and 18% women). Cancer deaths are superseded only by heart disease which is responsible for 42% of elders' deaths. Cancer is typically associated with some degree of physical pain but older adults are often left untreated for their cancer pain (Jacox, 1994, p. 127). Health care professionals as well as the patient themselves may view pain as a normal part of aging which can hinder appropriate pain management (Jacox, 1994, p. 127).
Recent pain management guidelines (Jacox, 1994, p. 127) indicate "The elderly should be considered J an at-risk group for the under-treatment of cancer pain because of inappropriate beliefs about their pain sensitivity, pain tolerance, and ability to use opiates. Elderly patients, like other adults, require aggressive pain assessment and management." Evidence exists that older people may in fact experience more pain than younger people (Jacox, 1994, p. 129). One can empathize with older persons' fear of cancer related to the associated high incidence of death as well as their fear of pain identified with the cancer death. Inappropriate management of pain for older people may help to explain a suicide attempt and requests for assistance from the health care professional with these acts.
The incidence of suicide among people with cancer is relatively small although the risk increases with poorly controlled pain (Jacox, 1994, p. 132). Sixty-nine percent of patients with cancer reported that they would consider suicide if their pain were not adequately treated. Those who were considering suicide often change their minds once their pain is relieved (Foley, 1991). Greene and Davis (1991) report that when symptom control is effective, cancer patients no longer need to request assisted suicide as a means of deliverance.
While the majority of cancer patients want to live for as long as they can, there are those who prefer death to their existing quality of life (Stephany, 1994). The issues for these people do not center on pain or symptom control but rather on not being a burden (personally or financially) to their families. They are realistic about the course of their disease and would rather not travel down that road.
This month's Your Turn responses indicate that although some nurses are asked to assist a client to end their lives, none admit to helping them to die. Management of pain is a major concern for these nurses. As a profession, we are very clear regarding the code for nurses when caring for clients at the end of their lives; therefore we do need to acknowledge a candor factor in this month's responses. We asked nurses about an illegal act. While some may acknowledge being asked, none will admit to an affirmative response.
- Baton, M.P. (1991). Euthanasia: The way to do it, the way they do it. Journal of Pain and Symptom Management, 6(5), 298-305.
- Foley, K. (1991). The relationship of pain and symptom management for physicianassisted suicide. Journal of Pain and Symptom Management, 6(5), 289-297.
- Greene, W.R., & Davis, W.H. (1991). Titrated intravenous barbiturates in the control of symptoms in patients with terminal cancer. Southern Medical Journal, 84(3), 332-336.
- Jacox, A., et al. (1994). Management of cancer pain. Clinical practice guideline, No. 9 (March), AHCPR publication no. 94-0592. Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health & Human Services, Public Health Service.
- Stephany, TM. (1994, July /August). Assisted suicide: How hospice fails. The American Journal of Hospice & Palliative Care, 4-5.
- Voluntary Euthanasia Society, The (Ed.). (1992). Your ultimate choice: The right to the with dignity. London: Souvenir Press.