Assisted Suicide: What Role for Nurses?
Nursing Spectrum, 15
Copyright 2000. All rights reserved. Used with permission. Nursing
Spectrum provides this article as an informational service and takes no
position on assisted suicide.
[The hospice agency for which Jill Allene, RN,
works has cared for four patients who chose PAS
under Oregon's Death with Dignity Act.]
On a cold Friday in January, Oregon nurse Jill
Allene, RN, visited her elderly hospice patient,
Gus,* as she
had many times before. Her eyes moved over him
slowly, assessing him closely. They joked about
baseball, about family, about life. When she
finished, she gathered her belongings, extending her
hand to him as they said their goodbyes. The next
day, surrounded by those he loved, Gus swallowed a
lethal mixture of medications that had been
prescribed by his physician and fell into a deep
sleep. He died soon after, wearing his favorite
Gus didn't win his battle with disease, but he
did win a war - a war of control. He wanted simply
to die on his terms, under circumstances he chose.
Like others in Oregon who have opted to use that
state's legalized physician-assisted suicide (PAS),
it wasn't unrelenting surges of pain or
incapacitating waves of nausea that encouraged Gus
to call it quits; it was an unquenchable thirst for
autonomy. Pulmonary disease didn't kill Gus - Gus
"This man was not the picture of suffering as I
know it," says Allene, who, though she did not
witness the death, was a party to it all the same.
Since Oregon broke new ground with its 1997 Death
with Dignity Act - becoming the only state in the
nation to legalize PAS - nurses there are assuming
roles they may not have anticipated, sometimes
uncomfortably so. Ironically, Oregon's nurses are
finding themselves, not physicians, on the front
line of PAS. It's a place where physicians might
actually prefer them and one to which some nurses
have already gone.
"Initially, when the law was designed, the
assumption was that physicians would be the first
ones to explore PAS with patients," says Pam
Matthews, RN, BSN, administrator for Evergreen
Hospice, Albany, OR, "but in reality, nurses are
usually the ones in the line of fire. Patients often
feel nurses understand their wishes for good quality
of life and good quality of death, too."
Much of nurses' roles lies behind the scenes long
before the drama of PAS unfolds. Home care and
hospice nurses actively help patients understand
their rights, acting as advocates for those who are
"Patients often ask about PAS," says Allene.
"They want to learn more and feel comfortable asking
their nurses about it."
Allene's agency has cared for four patients who
have opted to use PAS. Gus was Allene's first such
patient. "Our entire hospice team was involved in
this patient's case - all trying to pick his brain,
making sure he had no unmet needs we could fill or
pain that was going untreated," she says. "We wanted
to be sure that he saw all possible options before
It's that kind of strong patient advocacy that
has physicians - in general opposed to PAS -
speculating whether nurses are better-suited to a
more direct role in the process. Some physicians
have stated publicly that they may not be the best
members of the healthcare team to lead assisted
dying, confessing that they are not always the most
properly prepared for the task. A recent article in
the Annals of
Internal Medicine (AIM) stated PAS violates
physicians' professional integrity and suggests that
other disciplines, such as nursing, may be more
capable of leading assisted-dying efforts.1
"To say that physicians alone are the only ones
capable of assisting a patient's suicide is not that
easy," says Jason Karlawish, MD, of the University
of Pennsylvania Center for Bioethics' Assisted
Suicide Consensus Panel, and coauthor of the AIM
article. "The problem is that it [PAS] requires
skills that the average physician does not have -
and shouldn't have. We [physicians] should be able
to treat those who are dying, relieving their pain
and symptoms, but not helping them kill themselves."
Although nurse practitioners (NPs) can write
prescriptions for schedule II medications in Oregon,
nurses like Allene are hoping the current law will
evolve to include expanded PAS rights for NPs. Or,
suggests Karlawish, "maybe a new profession should
be created to perform PAS - a nurse with additional
certification, or a physician with additional
certification. This is too significant an act to not
know what you're doing."
Knowing what you're doing and doing it are
completely different matters, particularly when it
comes to assisted dying. PAS divides many in
nursing. "Many RNs believe that to intentionally
assist another in dying is to participate in
killing," says Judith Kennedy Schwarz, RN, MS,
doctoral candidate, division of nursing, New York
University, and a consultant in nursing ethics and
expert in the subject of assisted dying. "They see
it as disrespect for life and something that''s
prohibited by law, our nursing code of ethics, and
our practice guidelines." Other nurses see the issue
quite differently. Assisted dying, they say, goes on
every day in subtle, unspoken ways.
"I think a lot of nurses out there have given
someone a little too much morphine at one time to
ease a patient's pain," says B, a hospice nurse from
Seattle, who asked for anonymity, "and they do so
knowing full well the consequences of their
The American Nurses Association believes nurses'
participation in assisted suicide violates the
ethical standards of its Code for Nurses. The
association draws a distinction between nurses'
participation in assisted suicide and euthanasia and
their provision of medications that have the
unintentional effect of ending a patient's life.
"The nurse may provide interventions to relieve
symptoms in the dying client," the code states,
"even when the interventions entail substantial
risks of hastening death."2
But a recent survey of oncology RNs supports the
theory that some nurses do, in fact, help the dying
process along. The survey found that nurses (4%)
were more likely than physicians (1%) to carry out
patient-requested euthanasia - a deliberate and
intentional act that causes the death at a patient's
request, such as administering a lethal injection,
as opposed to assisted suicide, defined as the
provision of a means to end life, such as a
prescription for a lethal amount of a drug or the
Of the 441 nurses surveyed, 30% reported
receiving requests for lethal drugs in the previous
year, and 25% of nurses reported requests for lethal
injections. One percent of the RNs admitted helping
a patient commit suicide, 4.5% reported performing
patient-requested euthanasia, and 2% admitted
injecting a lethal drug into a patient more than
once in the previous year.3
Ironically, nurses who had participated in assisted
dying frequently consulted physicians but rarely
approached another nurse for support.4
"It's hard to find anyone who will talk about
helping patients die, whether it be illegal
euthanasia or legal PAS,"" says an Oregon nurse.
"It''s still quite taboo for anyone to talk about
PAS, and nurses are among them, despite its
legality." It's also difficult for patients to find
a physician who will talk to them about PAS or
consider writing them a prescription for the lethal
medication. Some patients visit several physicians
before they find one who will help them carry out
PAS. Currently, only one in 10 patients who request
PAS are given a prescription for it.
But even when nurses support PAS, they might not
understand how they feel about assisted dying until
they're faced with it.
"Although I support the patient's right to die,
I'm always saddened by the fact that some people
don't choose life," says Lynda Moses, RN, BSN, a
nurse at a Portland-area hospice who felt pulled in
opposite directions when her patient chose PAS.
"I had felt OK with the law until it actually
became a reality for one of my patients," she says.
"When the patient's physician asked me if I'd be
willing to be present when the patient took his own
life, I was surprised to find myself in a quandary.
I could see myself being there and crying out,
Moses was relieved that her patient died of
natural causes shortly before he was to take his own
life. "It made me realize just how uncomfortable I
was about PAS, even though I still believe it should
be a patient's right. I have no problem caring for
patients after they've taken lethal prescriptions -
I just don't want to be there when they do."
She isn't alone. Nurses across Oregon report
confusion about their feelings toward PAS, although
many hospices were preparing for the law's fallout
long before it hit the books.
"Before PAS became law, it was publicly debated,
and we performed surveys of our hospice teams'
feelings on the issue," Matthews says. "We found
that most nurses felt strongly that patients should
have the choice of PAS, although most said they
would not participate in the event."
Legal - and Lethal
Drawing national attention in November 1994 when
it was first passed, Oregon's Death with Dignity Act
was held in limbo by a court injunction for nearly
two years. The law was finalized in October 1997.
The act legalizes PAS, but clearly prohibits
euthanasia. Ironically, however, the only legal
"assistance" physicians may provide for terminally
ill patients a prescription for a lethal dose of
medication. No recipe or magic potion exists -
physicians work with pharmacists to tailor-make a
mixture for each patient. Patients take the oral
medication themselves and must meet other stringent
criteria before a prescription is written.
Aside from being a legal resident of Oregon,
anyone interested in PAS must be at least 18 years
old and capable of communicating his or her
healthcare decisions. Patients must also be
diagnosed with a terminal illness and have fewer
than six months to live. The request for PAS must be
voluntary. One written and two verbal requests must
be made, and the verbal requests for PAS must be
separated by at least 15 days. A consultant
physician must confirm a patient's terminal
diagnosis, and if either the consultant or the
patient's physician suspects the patient may be
depressed, a thorough psychiatric examination must
be performed. The patient must also be made aware of
comfort measures that are available through hospice
Not everyone in the state has the right to PAS.
According to a 1998 Oregon Health Division report,
federal law prohibits participation in PAS by
patients or physicians within federal healthcare
systems, such as Veterans Administration hospitals.
Some private healthcare systems, including one
Catholic medical system in Oregon, have placed
similar restrictions on patients and staff within
Between 1998 and 1999, more than 43 patients have
taken advantage of their right to commit legalized
suicide in Oregon. The average patient was 71 years
Death Be Not Chosen
Before PAS became law, opponents theorized that
Oregon would become a breeding ground for
Kevorkian-like physicians - physicians in the death
business. They also feared people would flock to the
state because of the availability of PAS. So far,
neither fear has become reality.
"We''re not seeing people come to Oregon to die.
And as far as 'death doctors,' we aren't seeing
that, either," says Matthews.
PAS opponents were also afraid people would
confuse hospice care with PAS and conclude that
hospices hasten death. Thankfully, that doesn't seem
to be the case, either.
"One consequence of PAS is that we have very
informed citizens," says Virginia Tilden, RN, DNSc,
FAAN, associate dean for research at Oregon's Health
Science University, Portland. "Oregonians understand
that they have the right to good pain management,
symptom control, and a better quality of dying. It's
a unique right of control, but a legal one all the
Legal - for now. The Pain Relief Promotion Act, a
federal proposal that would have the effect of
stripping Oregonians of their right to PAS, is
clipping along through Congress (see "Proposed
Legislation Would Mean Death for Assisted Suicide").
If passed, the legislation would prevent the Guses
of Oregon - or of any other state - from exercising
autonomy in their lives - and deaths.
This would be welcome news for some nurses, but
for others, bad tidings. "It's gut-wrenching to see
a terminally ill patient suffer," says B. "What's
happening in Oregon is a good thing - for patients
who want a choice."
*Name has been changed.
1. Faber-Langendoen K, Karlawish
J. Should assisted suicide be only physician
assisted? Ann Intern Med. 132:483.
2. American Nurses Association.
Position statement on assisted suicide.
Accessed May 2, 2000.
3. Kennedy Schwarz J. Assisted
dying and nursing practice. Image J Nurs Sch. 1999;
4. Matzo LaPorte M, Emmanuel EJ.
Oncology nurses' practices of assisted suicide and
patient-requested euthanasia. Oncol Nurs Forum.
Oregon's Death with Dignity Act: The first year's
experience. Accessed April 5, 2000.
6. Oregon Health Division,
1998 Annual Report on Oregon's Death with Dignity
Act. Accessed April 5, 2000.