Some Nurses Still Need End-of-Life Education
A Virginia critical care nurse recently faced charges related to a morphine overdose she intentionally administered in 1999 to an 80-year-old male patient at the end of life. The elderly patient with an active do-not-resuscitate order had suffered a cardiac arrest, sustained brain damage from the arrest, and was comatose. The nurse deliberately administered over 200 milligrams of intravenous morphine to her patient with the intent to speed the dying process. In this particular case, the nurse avoided murder charges when laboratory tests revealed that the patient had not died as a direct result of her narcotic overdose. After promising the court she would never practice nursing again, the nurse was charged with a narcotic violation and was given a suspended sentence (Washington Post, May 31, 2000). During the court proceedings it was revealed that this was the second time the nurse had administered a morphine overdose to a patient she was caring for at the end of life.
The morphine overdoses administered by the Virginia nurse are clear examples of active euthanasia and are morally prohibited by the nursing profession. Nurses are trusted by society to respect and protect human life (Nursing's Social Policy Statement, 1995) (See Below) and taking deliberate action to hasten the death of a patient, through acts of euthanasia or assisted suicide, is never permissible. The Code for Nurses, clearly states that the nurse has a moral obligation to prevent and relieve the suffering of dying patients but must never act deliberately to terminate the life of any person. Administering an overdose of intravenous morphine with the intent of speeding the dying process is contrary to the values and moral obligations of the profession.
Some nurses remain unclear about their moral obligations to dying patients and are confused regarding the nurse's role in relief of suffering and promotion of comfort to the dying patient. Nurses' moral and ethical obligations related to relief of pain at the end of life, euthanasia, and assisted suicide are clearly defined in the Code for Nurses and position statements developed and approved by the profession. These documents not only address differences between euthanasia and assisted suicide but also discuss acceptable actions nurses may take to ease suffering at the end of life.
It is clear that nurses have an ethical obligation to relieve suffering associated with the dying process. The nurse caring for a dying patient must not hesitate to respond to a patient's pain level with full and effective pain medication. In fact, the nurse has a central role in assessing the presence of pain in the dying patient and assuring that the patient at the end of life has pain controlled to a level that is acceptable to the patient. In order to combat the development of drug tolerance, increasing narcotic dosage to achieve pain control and promote comfort at the end of life is often necessary. The American Nurses Association's position statement, Promotion of Comfort and Relief of Pain in Dying Patients, 1991 directs nurses to use full and effective doses of pain medication to achieve adequate symptom control even if death is hastened as a result. In this situation, relief of pain and promotion of comfort is the intended effect, and the hastening of death may result secondarily from the drug's side effects on consciousness and respiration. For the dying patient, the relief of pain and promotion of comfort is a primary goal and administering increasing doses of medication to achieve this goal is ethical even when the risks of death are increased (President's Commission for the Study of Ethical Problems in Medicine, 1983). However, nurses must be clear regarding the moral differences between the actions of providing effective pain relief to a dying patient and participating in euthanasia or assisted suicide.
Acting to promote comfort and relieve pain in the dying patient is morally different from the actions of the Virginia nurse. In the latter situation, the nurse's intent was to purposely accelerate her patient's death by means of a narcotic overdose. Her action was a clear example of active euthanasia, as defined by the American Nurses Association, and violated the ethical code of the profession. When a nurse purposively acts to hasten a patient's death, the nurse, not the dying process, becomes the immediate cause and agent of death. In this context the nurse independently determines the circumstances of the patient's death, and makes a decision that is not morally acceptable. In the case of the Virginia nurse, the decision was to independently control and speed the dying process.
Although the words euthanasia and assisted suicide are often used interchangeably in the popular media, the terms have distinct definitions. Euthanasia, or "mercykilling", is an intentional act which involves putting to death someone who is experiencing suffering or prolonged dying (ANA Position Statement: Active Euthanasia, 1994). Assisted suicide involves helping an individual secure a means to take their own life, with full knowledge of the person's intent (ANA Position Statement: Assisted Suicide, 1994). Euthanasia differs from assisted suicide in that someone, other than the patient, not only provides the means of death, but also acts as the agent of death.
It was reported by a co-worker that the father of the Virginia nurse had experienced a painful death when he was not given sufficient medication to relieve his suffering at the end-of-life. The nurse on trial also stated she wanted to assist the family in putting the patient's death behind them (Washington Post, May 31, 2000). In addition to understanding the implications of the Code for Nurses and related position statements on dying, nurses have a responsibility to reflect on how their personal experiences with death and dying may affect the care they give to their patients. Nurses' awareness of personal attitudes and values regarding death and dying assists in the delivery of nursing care that upholds the ethics of the nursing profession. Personal awareness of attitudes, beliefs, and values and how these may influence nursing judgement in the provision of end-of-life care are helpful in shaping nursing decisions as well as actions.
References:
American Nurses Association (1985). Code for Nurses With Interpretive Statements. Kansas City, MO. (See Below)
American Nurses Association (1995). Nursing's Social Policy Statement. Washington, D.C (See Below)
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment. Washington, D.C.: U.S. Government Printing Office.
Washington Post (May 31, 2000). Nurse Avoids Prison in VA Overdoses. Page B2.
American Nurses Association Position Statements:
Active Euthanasia (1994) (See Below)
Assisted Suicide (1994) (See Below)
Promotion of Comfort and Relief of Pain in the Dying Patient (1991) (See Below)