SM Valente, VAGLAHS

Objectives: Describe RNs' justifications for euthanasia. Describe RNs difficulties caring for suicidal patients and related issues. Dissatisfied with end-of-life care, Americans fear a non-peaceful death and unwanted, aggressive treatment and prolonged pain. More than 60% of dying patients report unmanaged pain, 30% of physicians disregarded advance directives, and 35% of physicians refused a patient’s request to discontinue life support (McCarthy, 1997). About 30% of terminally ill patients want to die sooner due to distressing symptoms or poor quality of life. Many people spend 8 days in ICU either comatose or on a ventilator before dying; whether they wanted these treatments is unclear. Scant research illustrates the nurse’s responses to requests for euthanasia or assisted suicide. Courts judged one RN guilty of assisting euthanasia Muller, 2000).

Methods: From a stratified, random, national survey of 1200 Oncology Nurses Society clinical RNs, 445 (37%) surveys were analyzed. Using content analysis we analyzed RNs' narratives about circumstances justifying euthanasia and difficulties with suicidal patients. We reread narratives and developed categories (Downe, Wamboldt, 1992). Independent coding and team consensus established stability, reliability, credibility and dependability of analysis (Lincoln & Guba, 1985). A focus group provided further clarification of themes.

Results: Oncology RNs hold diverse moral and spiritual values and beliefs. Themes included: euthanasia was not/never justified (n=122); justified by terminal illness with pain or poor quality of life (n=69); poor symptom control (n=61); patient autonomy (n=30); incurable illness/permanent disability (n=23); clinical death (n=15); terminal illness only (n=14) and unsure (n=11). RNs reported euthanasia could occur (secondary effect) and some reported mixed personal/professional justifications (n=4). Difficulties caring for suicidal patients emerged from (a) religious/spiritual beliefs or values about suicide; (b) uncomfortable feelings; (c) inadequate skills, knowledge or experience; (d) personal experience with a loved one’s suicide; (e) professional responsibilities. The focus group explained that providing care for terminally ill, elderly adults from other cultures and with unmanaged symptoms was difficult.

Conclusions: Nurses hold conflicting views of their professional, legal, and ethical duties when patients consider euthanasia or assisted suicide. Advocacy roles, mental status or symptom assessment and use of consultation were rarely documented. Some confusion about terms existed (e.g., murder or secondary effect). RNs wanted education about palliative care, ethical dilemmas, suicide management, consultation, and more research to guide practice. RNs need to forge clear policy that outlines their professional roles. If assisted suicide becomes legal for physicians, RNs will confront complex dilemmas about their advocacy role.

Impact: RNs hold diverse views about euthanasia and assisted suicide and need education about bioethical dilemmas, end of life care, and evaluation of patients seeking euthanasia or assisted suicide. Inadequate symptom management and excessive, unwanted, and futile technical medical care at end-of-life represent a substantial burden to the VA healthcare system. Despite professional codes, physicians and RNs have assisted suicide (Asch 1996; Stevens & Hassan, 1994; Schwartz, 2000. This study highlights RNs reasons for support of euthanasia and shows need for education, skill building and consultation to improve interventions for pain and symptom management, evaluation of mental status, and quality of care.