The Role of Nurses When Patients Decide to End Their Lives

Some hospitals and hospices have policies that forbid nurses to be part of the process or even to discuss end-of-life options.

New York Times

Emilie Le Beau Lucchesi

When Ben Wald, 75, was dying of cancer in 2012, he wanted to use Oregon’s Death with Dignity Act to receive a prescription for a lethal medication that would end his life. His hospice nurse, Linda, was part of the discussion and provided both information and support, said his wife, Pam Wald, of Kings Valley, Ore.

His colon cancer had spread to his lungs, and his weight dropped from 180 to 118 pounds. He struggled to speak or eat.

When he was ready to end his life, the couple wanted Linda with them, but the hospice organization she worked for did not allow it, Mrs. Wald said. The organization allowed other hospice workers, such as social workers and massage therapists, to be present, but not the doctors or nurses it employed. . . [Full text]

Politicians call on public to oppose Fraser Health making hospices offer euthanasia

Surrey Now Leader

Heather Colplitts

Fraser Health’s decision to have hospices offer medically assisted dying prompted a couple hundred people to gather Saturday to discuss how to fight back.

A Saturday evening meeting about the local health authority allowing medical assistance in dying (MAiD) included a discussion on whether there’s a possible legal case, and what people, hospice societies and volunteers can do if they disagree with the health authority.

All B.C. health authorities have said their various facilities would provide MAiD. Fraser Health funds the hospice residence near Langley Memorial Hospital where terminally ill people are able to receive care. The society has offices and space for its various bereavement programs at 20660 48th Ave. and has a contract with Fraser Health to provide volunteers for the residence. . . [Full Text]

Court decision on assisted suicide referrals opens door for other challenges

The Catholic Register

Michael Swan

While doctors who lost their right to practise medicine according to their conscience contemplate a legal appeal, a prominent pro-euthanasia organization suspects faith-based hospitals, nursing homes and hospices may be next to face demands to accommodate euthanasia and assisted suicide.

Dying With Dignity, Canada believes an Ontario Divisional Court decision that compels doctors to refer for euthanasia and assisted suicide may become a springboard to court challenges aimed at the conscience rights of institutions which refuse to assist in the death of patients.

“It’s really interesting. I think that the question is going to be debated in the coming days and weeks, if not months, by lawyers,” Dying with Dignity CEO Shanaaz Gokool told The Catholic Register.

In a unanimous Jan. 31 decision, a panel of three judges agreed that the religion rights of doctors under the Charter are violated by a policy which demands a formal referral for assisted suicide and other procedures. But the judges nonetheless ruled against the doctors because, they said, there is a greater public interest in ensuring “equitable access to such medical services as are legally available.” . . . [Full Text]

The Alarming Trend Of Bullying Hospitals And Hospices Into Assisted Suicide

Huffington Post

Reproduced with permission

Dr. Will Johnston

Canadians who are sick and suicidal can now be put to death under various medicalized and government-approved protocols, following court and legislative victories by euthanasia activists. These activists are now turning their considerable talents to a coercive makeover of the palliative hospice movement by demanding that hospices founded on a promise to never deliberately hasten death should provide a death

Before they got their way in the Canadian Supreme Court, the public posture of euthanasia advocates was one of caution, reassurance and limitation of objectives. After their victory, partisans of the medical killing movement have become impatient with individuals or institutions who want no part in suicide and euthanasia. Activists recommend expanding access to include all the people who were strategically excluded from the plan that had been sold to the public: children, people with chronic nonfatal conditions, the physically disabled, the cognitively disabled, psychiatric patients.

Now, even changing the location of a patient requesting suicide — from a euthanasia-free hospital or hospice, to one that does offer it — is being protested as a cruel imposition. In doing so, the death-seeking person is set up as a victim, and the hospital or hospice is portrayed as a victimizer. Never mind that hospital wards routinely transport people in complete comfort to procedures like X-rays or scopes, or to another location to continue care.

The implications of this are dire. Many hospices serve patients who want nothing to do with assisted suicide, and there will be much harm done by forcing it into their midst. Every community in this country has the resources to provide a distinct euthanasia-free space. That distinct space and its staff could be specialized and uncoerced into death-hastening.

The unpleasant alternative was demonstrated by the recent “sneak attack” on Louis Brier Hospital, a Jewish retirement home in Vancouver. This was the work of euthanasia activist Ellen Wiebe, idolized by like-minded columnists for her aggressive death-providing practice. Rather than arrange a simple transfer — perhaps to the home of one of the suicidal father’s daughters — the patient was killed by Dr. Wiebe against the firm policy of a facility with an understandable aversion to euthanasia.

As Louis Brier’s director protested, “We have a lot of Holocaust survivors. To have a doctor sneak in and kill someone without telling anyone. They’re going to feel like they’re at risk when you learn someone was sneaking in and killing someone.”

What Dr. Wiebe was doing by giving the finger to Louis Brier is a form of ethical bullying, masquerading as an altruistic claim that her client should come first and trump other people’s rights about the kind of place they want to live in.

Wanting Dr. Wiebe to kill you is a tragedy, not an emergency. It is a personal preference, sadly now provided by the Canadian health-care system, but without any judicial or parliamentary authorization to force others to accept involuntary proximity to your actions. It is also, increasingly, about people who are not dying, except in Dr. Wiebe’s elastic interpretation, but about those who have lost meaning and hope. What they get from the euthanasia provider amounts to a heartless endorsement of the hopelessness of their situation, cloaked in the language of autonomy.

Rather than look for a win-win compromise over this issue, the board of Fraser Health Authority, a large B.C. hospital system, has imposed euthanasia provision in all its palliative hospices. This edict, totally uncalled for by provincial or federal guidelines, caused the high-profile resignation of Palliative Care Medical Director Dr. Neil Hilliard.

Meanwhile, our governments are, in Dr. Hilliard’s words, “guilty by neglect” of a “palliative care access gap,” and your sick family member who seeks care, not death, may not find it “equitable or timely.”

Forcing hospices to betray their no-kill founding principles will not close that gap, it will just torpedo the 40-year struggle to convince often-fearful patients that palliative hospices are not about hastening death.

Fraser Health and any other misled health bureaucracies across Canada should back down. Don’t bully hospices as though there are no fair alternatives. Don’t bully Catholic hospitals, founded on a reverence for life long before the public purse got involved.

Assisted killing still part of Ontario’s palliative care plan

Catholic Register

Michael Swan

The agency responsible for expanding Ontario’s network of hospice care wants hospice patients to have the option of assisted suicide, even if most hospices and the majority of doctors oppose it.

“The OPCN (Ontario Palliative Care Network) promotes early and equitable access to hospice palliative care for all patients with a life-limiting illness, including individuals who have requested medical assistance in dying,” a spokesperson for the Ontario Palliative Care Network told The Catholic Register in an email.

The provincially-funded OPCN, a sub-agency of Cancer Care Ontario, “recognizes that there may be an intersection between palliative care and medical assistance in dying (MAID). Both medical assistance in dying and palliative care are health care services that exist within the health care system,” wrote Cancer Care Ontario communications advisor Jayani Perera. “However, the focus and mandate of the Ontario Palliative Care Network is advancing palliative care in the province.”

A year into legalized killing in Canada, the big question is how palliative care and hospice beds will be expanded, said bioethicist Bob Parke. Will governments fund hospices that refuse to perform or refer for assisted dying? . . [Full text]

 

B.C. hospices say they’ve been told to offer euthanasia

Lifesite News

Steve Weatherbee

BRITISH COLUMBIA, October 21, 2016 (LifeSiteNews) – Two of British Columbia’s five regional health authorities — one of them covering the “Bible Belt” area of the lower Fraser River valley just east of Vancouver — apparently have told voluntary societies offering hospice and palliative care that they must provide euthanasia and assisted suicide.

The Fraser Health Authority and its unnamed ally are not only flying in the face of — and against the philosophies and binding constitutions of most if not all the province’s 73 voluntary hospice societies — they have done so without consulting the hospice societies in their own regions. Apparently they have also jumped the gun on the provincial Health Ministry, which is months away from finalizing its own policy. . . [Full text]

Ethical Issues Experienced by Hospice and Palliative Nurses

Journal of Hospice and Palliative Nursing. 2015;17(1):7-13.

Jooyoung Cheon, Nessa Coyle, Debra L. Wiegand, Sally Welsh

Abstract

Nurses encounter ethical dilemmas in their clinical practice especially those associated with palliative and end-of-life care. The Hospice and Palliative Nurses Association (HPNA) members were asked to participate in an ethics survey. The survey aimed to identify ethical issues experienced by hospice and palliative nurses, identify resources available to them and barriers if any to their use, and to identify how HPNA can be of support to hospice and palliative nurses.

One hundred twenty-nine (n = 129) HPNA members completed the online survey. The information from each of the surveys was carefully reviewed, and responses were collapsed into 6 themes.

The ethical dilemmas included inadequate communication, provision of nonbeneficial care, patient autonomy usurped/threatened, issues with symptom management and the use of opioids, issues related to decision making, and issues related to discontinuing life-prolonging therapies.

Approximately two-thirds of the nurses used resources in an attempt to resolve the ethical issues, including a formal ethics consultation, involvement of the palliative/hospice team, consulting with other professionals, and use of educational resources.

One-third of the nurses said there were institutional or personal barriers that prevented the ethical dilemma from being resolved. Participants suggested ways that HPNA could help them to effectively manage ethical dilemmas. [Full text]

 

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 8: Hospitality and Lethal Injection

Abstract

Under the Act Respecting End of Life Care (ARELC) palliative care hospices may permit euthanasia under the MAD protocol on their premises, but they do not have to do so.  Patients must be advised of their policy before admission.  The government included another section of ARELC to provide the same exemption for La Michel Sarrazin, a private hospital.  The exemptions were provided for purely pragmatic and political reasons.

The exemptions have been challenged by organizations that want hospices forced to kill patients who ask for MAD, or at least to allow physicians to come in to provide the service.  Hospice representatives rejected the first demand and gave mixed responses to the second.  A spokesman for the Alliance of Quebec Hospices confirmed that palliative care hospices that provide euthanasia will not be excluded from the Alliance.

A prominent hospice spokesman predicted that the pressures would increase after the passage of ARELC, and that hospices refusing to provide euthanasia would operate in an increasingly hostile climate.

A former minister of health rejected the challenges to the exemptions and insisted that the policy of hospices be respected, appealing to the principles of autonomy and freedom of choice.  Consideration of freedom of conscience is irrelevant to this approach, and the description of the problem as a conflict of autonomy actually precludes a successful resolution by an appeal to the principle giving rise to it.

While the former minister of health wanted the autonomy of hospices explicitly set out in law, the only requirement in ARELC is that regional health authorities consult with institutions and palliative care hospices in their territories before making rules.  Mere consultation may be insufficient to protect the integrity of hospices in the long term. [Full Text]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 4: The Problem of Killing

Abstract

Impartiality, complicity and perversityThe original text of Bill 52 did not define “medical aid dying” (MAD), but it was understood that, whatever the law actually said, it was meant to authorize physicians to kill patients who met MAD guidelines.  The Minister of Health admitted that it qualifed as homicide, while others acknowledged that MAD meant intentionally causing the death of a person, and that its purpose was death.  Various witnesses in favour of the bill referred explicitly to lethal injection and the speed of the expected death of a patient.

Given the moral or ethical gravity involved in killing, it is not surprising to find serious disagreement about MAD among health care workers.  Conflicting claims made about the extent of opposition to or support for euthanasia within health care professions are difficult to evaluate, but a review of the transcripts of the legislative committee hearings into Bill 52 is instructive.

One physician member of the committee was shocked by the assertion that there is no  moral, ethical, or legal difference betwen withdrawing life support and lethally injecting a patient.  Hospices and palliative care physicians rejected participation in euthanasia.  Sharp differences of opinion among other health care workers were reported.  Support for killing patients by lethal injection was likened to support for the death penalty; that is, many more agreed with the act in principle than were willing to do the actual killing.  So marked was the evidence of opposition to euthanasia that doubts were raised about the possiblity of implementing the law.

Since the law was passed as a result of assurances from the Quebec medical establishment that it could be implemented, a committee member who is now a minister of the Quebec government warned that they would be called to account if it is found that few physicians are willing to participate.  This political pressure is likely to provide an additional incentive for the medical establishment to secure the compliance of Quebec physicians.

The introduction of euthanasia into Quebec’s health care system is to be accomplished using the structures and powers established by other Quebec statutes that govern the delivery of health care in the province, which have established a multi-layered and overlapping bureaucracy of committees, councils, commissions, boards, directors, examiners, coordinators, syndics and commissioners.  Physicians and other health care providers who object to euthanasia will find their working environments increasingly controlled by a MAD matrix functioning within this system, a prominent feature of which is an emphasis on patient rights.

Everyone authorized to enact or supervise adherence to policies or standards can become a MAD functionary, using codes of ethics, protocols, guidelines, directives, etc. to normalize euthanasia. Similarly, every disciplinary and complaints procedure can be used to force participation in MAD services.  Those who openly advocate refusal to provide or facilitate euthanasia can be fined from $1,500.00 to $40,000.00 per day under Quebec’s  Professional Code if they are deemed to have helped, encouraged, advised or consented to a member of a profession violating the profession’s code of ethics. [Full Text]

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 1: Overview


Abstract

An Act Respecting End-of-Life Care (“ARELC”) is intended to legalize euthanasia by physicians in the province of Quebec.  It replaces the original Bill 52, the subject of a previous commentary by the Project.  The original text of the Bill 52 did not define medical aid in dying (MAD), but ARELC now makes it clear that Quebec physicians may provide euthanasia under the MAD protocol.  In addition, substitute decision makers can order legally incompetent patients who are not dying to be starved and dehydrated to death.  This practice, identified here as Euthanasia Below the Radar (EBTR), is completely unrestricted and is not even reportable.

Neither ARELC nor MAD guidelines can abolish the criminal prohibition of euthanasia, so physicians who kill patients in the circumstances contemplated by the new law would still be liable to prosecution.  However, the Quebec government has promised that it will refuse to prosecute physicians who kill patients in accordance with MAD guidelines, thus circumventing the criminal prohibition.  Beyond that, Quebec general practitioners have asked for immunity from prosecution for failing to conform to MAD guidelines.  Some Quebec physicians may be unwilling to provide euthanasia while the criminal law stands. Quebec’s Attorney General may be unwilling to provide the extraordinary kind of immunity sought by physicians, and some physicians may be unwilling to provide euthanasia without it.

The introduction of euthanasia will require the complicity of thousands of health care workers and administrators.   Many are likely to comply because official representatives of the legal and medical establishments of Quebec have formally declared their support for the new law.  On the other hand, palliative care physicians, hospices and an undetermined number of other physicians and health care workers are opposed to euthanasia and assisted suicide.

Section 4 of ARELC states that eligible patients have a right to “end-of life-care,” which includes euthanasia and palliative care.  The statutory declaration of a “right” is the most powerful weapon in the legal arsenal likely to be used to enforce compliance with ARELC and to attack freedom of conscience among those who refuse to facilitate the procedure.

It appears that, even where euthanasia or assisted suicide is legal, the majority of physicians do not actually provide the services.  The Act may lead to discriminatory screening of physicians unwilling to kill patients, effected by denying them employment in their specialties and denying them hospital privileges.

However, objecting physicians not only refuse to kill patients, but also often refuse to do anything that they believe makes them morally responsible for the killing. Hence, it is likely that most of the attacks on freedom of conscience resulting from ARELC will be precipitated by refusal to participate indirectly in killing.

Physicians may refuse to provide euthanasia if the patient is legally ineligible, and for other reasons, including conscientious objection.  ARELC requires physicians who refuse to provide euthanasia for any reason other than non-eligibility to notify a designated administrator, who then becomes responsible for finding a MAD physician.  The idea is to have the institution or health care system completely relieve the physician of responsibility for facilitating the procedure.

The protection of conscience provision in ARELC distinguishes physicians from other health professionals, providing less protection for physicians than for others.  Physicians may refuse only  “to administer” euthanasia – a very specific action –  which seems to suggest that they are expected to participate in other ways.

Palliative care hospices and a single Quebec hospital may permit euthanasia under the MAD protocol on their premises, but they do not have to do so.  Patients must be advised of their policy before admission.  The exemptions were provided for purely pragmatic and political reasons.  The exemptions have been challenged by organizations that want hospices forced to kill or allow the killing of patients who ask for MAD. Hospice representatives rejected the first demand and gave mixed responses to the second.  A prominent hospice spokesman predicted that hospices refusing to provide euthanasia will operate in an increasingly hostile climate.

Refusing to participate, even indirectly, in conduct believed to involve serious ethical violations or wrongdoing is the response expected of physicians by professional bodies and regulators.  It is not clear that Quebec legislators or professional regulators understand this.  A principal contributor to this lack of awareness – if not actually the source of it – is the Code of Ethics of the Collège des médecins, because it requires that physicians who are unwilling to provide a service for reasons of conscience help the patient obtain the service elsewhere.

As a general rule, it fundamentally unjust and offensive to human dignity to require people to support, facilitate or participate in what they perceive to be wrongful acts; the more serious the wrongdoing, the graver the injustice and offence.  It was a serious error to include this a requirement in a code of ethics.  The error became intuitively obvious to the Collège des médecins and College of Pharmacists when the subject shifted from facilitating access to birth control to facilitating the killing of patients.

A policy of mandatory referral of the kind found in the Code of Ethics of the Collège des médecins  is not only erroneous, but dangerous.  It purports to entrench  a ‘duty to do what is wrong’ in medical practice, including a duty to kill or facilitate the killing of patients. To hold that the state or a profession can compel someone to commit or even to facilitate what he sees as murder is extraordinary.

Since ARELC explicitly authorizes physicians to kill patients deemed eligible for MAD by the Act, the federal government can go to court to have the statute declared unconstitutional.  However, it is possible that the federal government will take no action until after the Supreme Court of Canada ruling in Carter v. Canada and after the 2015 federal election.

It seems unlikely that Quebec physicians who provide euthanasia under MAD guidelines will be prosecuted even if the prohibition of assisted suicide and euthanasia is maintained by the Supreme Court of Canada, and even if ARELC is ultimately struck down as unconstitutional.  The continued de facto decriminalization of euthanasia in Quebec would probably generate considerable pressure in other provinces to follow suit.

Those who refuse to provide or facilitate euthanasia for reasons of conscience will likely find themselves in increasingly complicated and contentious working environments. In the end, freedom of conscience for Quebec health care workers who object to euthanasia may come to mean nothing more than the freedom to find another job, or the freedom to leave the province. [Full text]