Retired ANA Position Statement
Originated by: Task Force on the Nurse's Role in End-of-Life Decisions Center for Ethics and Human Rights
Adopted by: ANA Board of Directors
Endorsed by: American Association of Critical Care Nurses Oncology Nursing Society
Related Past Action:
Code for Nurses With Interpretive Statements, 1985
The American Nurses Association (ANA) believes that the nurse should not participate in assisted suicide. Such an act is in violation of the Code for Nurses with Interpretive Statements (Code for Nurses) and the ethical traditions of the profession. Nurses, individually and collectively, have an obligation to provide comprehensive and compassionate end-of-life care which includes the promotion of comfort and the relief of pain, and at times, foregoing life-sustaining treatments.
There is a continuum of end-of-life choices that encompasses a broad spectrum of interventions from the alleviation of suffering, adequate pain control, do-not-resuscitate orders, withdrawing/withholding artificially provided nutrition and hydration, to requests for assisted suicide, and active euthanasia. Throughout this continuum nurses can respond to patients with compassion, faithfulness and support. Yet, nurses must understand the subtleties and distinctions of these issues in order to respond in a reasoned and ethically permissible manner.
In discussion of any controversial issue, one set of problems arises over definitions. Nurses and others interpret terms in vastly different and perhaps contradictory fashion. Thus clarification of language is essential. The first important distinction to make is that there are some end-of-life decisions that are fully consistent with the Code for Nurses and others that are not.
Suicide is traditionally understood as the act of taking one's own life. Participation in assisted suicide entails making a means of suicide (e.g., providing pills or a weapon) available to a patient with knowledge of the patient's intention. The patient who is physically capable of suicide, subsequently acts to end his or her own life. Assisted suicide is distinguished from active euthanasia. In assisted suicide, someone makes the means of death available, but does not act as the direct agent of death.
Withholding, Withdrawing and Refusal of Treatment:
Honoring the refusal of treatments that a patient does not desire, that are disproportionately burdensome to the patient, or that will not benefit the patient can be ethically and legally permissible. Within this context, withholding or withdrawing life-sustaining therapies or risking the hastening of death through treatments aimed at alleviating suffering and/or controlling symptoms are ethically acceptable and do not constitute assisted suicide. There is no ethical or legal distinction between withholding or withdrawing treatments, though the latter may create more emotional distress for the nurse and others involved.
Among the most controversial, vigorously debated and, at times, confusing issues within contemporary society is assisted suicide. The nursing profession is also struggling with the complex moral and professional questions surrounding this issue. Scientific and technological advances have made it possible to extend life and prolong the dying process. These advances have not necessarily provided for the enhancement of human dignity, personal control or improvement in care.
Nurses witness firsthand the devastating effects of debilitating and life-threatening disease and are often confronted with the despair and exhaustion of patients and families. At times, it may be difficult to find a balance between the preservation of life and the facilitation of a dignified death. Nurses need to recognize their own feelings of sadness, fear, discouragement and helplessness and realize the influence of these feelings on clinical decision making. These agonizing tensions may cause a nurse to consider intentionally hastening a patient's death as a humane and compassionate response, yet the traditional goals and values of the profession mitigate against it. The ANA Code for Nurses with Interpretive Statements (Code for Nurses) explicates the values and ethical precepts of the profession and provides guidance for conduct and relationships in carrying out nursing actions. It is within the framework of the Code for Nurses and professional standards that nurses make ethical decisions and discharge their responsibilities. The central axiom that directs the profession is respect for persons. This respect extends to and encompasses patients, families, nurse colleagues and team members. The principles of autonomy (self- determination), beneficence (doing good), nonmaleficence (avoiding harm), veracity (truth- telling), confidentiality (respecting privileged information), fidelity (keeping promises) and justice (treating people fairly) are all understood in the context of the overarching commitment to respect for persons. Nurses are challenged to uphold these principles as they confront the realities of professional practice.
Historically, the role of the nurse has been to promote, preserve and protect human life. The Code for Nurses states that respect for persons "extends to all who require the services of the nurse for the promotion of health, the prevention of illness, the restoration of health, the alleviation of suffering and the provision of supportive care of the dying. The nurse does not act deliberately to terminate the life of any person."
The profession of nursing is dominated by an ethic of care, an ideal that permeates and underscores all of nursing practice. The essence of caring takes place in the context of the nurse-patient relationship, the respectful and genuine presence of one human being to another. The perspective of care is a crucial and valuable dimension of ethical deliberation. From the perspective of care, nurses appreciate the emotional and contextual dimensions of ethical discernment. The uniqueness of individuals and the particular dynamics of relationships are recognized as integral components of the discernment process. The nurse's caring approach assists patients and families in finding meaning or purpose in their living and dying and furthers the attainment of a meaningful life and death.
- The profession's response to nurse participation in assisted suicide is grounded in the ethical traditions and goals of the profession, and in its covenant with society.
- The profession of nursing is built upon the Hippocratic tradition "do no harm" and an ethic of moral opposition to killing another human being. The ethical framework of the profession as articulated through the Code for Nurses explicitly prohibits deliberately terminating the life of any human being.
- Nursing has a social contract with society that is based on trust and therefore patients must be able to trust that nurses will not actively take human life. The profession's covenant is to respect and protect human life. (Nursing: A Social Policy Statement) Nurse participation in assisted suicide is incongruent with the accepted norms and fundamental attributes of the profession.
- Though there is a profound commitment both by the profession and the individual nurse to the patient's right to self-determination, limits to this commitment do exist. In order to preserve the moral mandates of the profession and the integrity of the individual nurse, nurses are not obligated to comply with all patient and family requests. The nurse should acknowledge to the patient and family the inability to follow a specific request and the rationale for it.
- Acceptance of assisted suicide practices has the potential for serious societal and professional consequences and abuses.
- While there may be individual patient cases that are compelling, there is high potential for abuses with assisted suicide, particularly with vulnerable populations such as the elderly, poor and disabled. These conceivable abuses are even more probable in a time of declining resources. The availability of assisted suicide could forseeably weaken the goal of providing quality care for the dying.
- Nurses must examine these issues not only from the perspective of the individual patient, but from the societal and professional community perspective. Involvement in community dialogue and deliberation will allow nurses to recommend and uphold initiatives, and provide leadership in promoting optimal end-of-life care.
- Assisted suicide is not to be confused with ethically justified end-of-life decisions and actions.
- The moral objection to the nurse's participation in assisted suicide does not diminish the nurse's obligation to provide appropriate interventions throughout the process of dying. Nurses must be vigilant advocates for humane and dignified care, for the alleviation of suffering and for the non-abandonment of patients.
- The withholding or withdrawal of life-sustaining treatment such as mechanical ventilation, cardiopulmonary resuscitation, chemotherapy, antibiotics and artificially provided nutrition and hydration can be ethically acceptable. Patients have the right to exercise their decisional authority relative to health care decisions, including foregoing life-sustaining treatments.
- The provision of medications with the intent to promote comfort and relieve suffering is not to be confused with the administration of medication with the intent to end the patient's life. "The nurse may provide interventions to relieve symptoms in the dying client even when the interventions entail substantial risks of hastening death." (Code for Nurses)
- Nurses should seek to understand the meaning of the request for assisted suicide and continue to demonstrate respect for and commitment to patients.
- It is not uncommon for patients to think about suicide during the course of illness. Requests for assisted suicide can be related to numerous factors including unrelieved pain and other symptoms, depression, feelings of loss of control, fear of isolation, concern for family and a sense of hopelessness. Nurses should avoid judgement of patients or their experience and recognize that only the suffering person can define that suffering.
- There are positive obligations to ascertain the patient's concerns, fears, needs and values, to discuss health care options and to provide counsel and support. Discussion of suicidal thoughts does not increase the risk of suicide and may actually be therapeutic in decreasing the likelihood. The relationship and communication between the nurse and patient can diminish feelings of isolation and provide needed support.
- Nurses have an opportunity to create environments where patients feel comfortable to express thoughts, feelings, conflict and despair. The issues that surround a request for assisted suicide should be explored with the patient, and as appropriate with family and team members. It is crucial to listen to and acknowledge the expressions of suffering, hopelessness and sadness. When possible, factors that contribute to such a request should be alleviated, and existing patient strengths and resources promoted and relied on.
- Nurses must identify and seek opportunities to demonstrate their lasting commitment to patients and families within the confines of professional practice. Efforts should be directed at the implementation of programs of palliative care to better manage chronic, severe bio-psycho-social and spiritual distress that limit quality of life and increase suffering.
- Nurses are obligated to listen compassionately to patients' requests, but must recognize the boundaries of acceptable ethical practice. Nurses can be honest with patients and acknowledge that they can not participate in assisted suicide, yet still manifest a commitment to non-abandonment.
- Acknowledging the prohibition against participation in assisted suicide does not necessarily lessen the distress and conflict a nurse may feel when confronted with a patient's request.
- Nurses may encounter agonizing clinical situations and experience the personal and professional tension and ambiguity surrounding these decisions. The reality that all forms of human suffering and pain cannot necessarily be removed except through death is not adequate justification for professional sanctioning.
- Nurses need to be aware of their own sense of suffering, discomfort, confusion and inadequacy. Acknowledgement of caregiver struggle and vulnerability can connect nurses deeply with the experience of the patient and family.
- Nurses should seek the expertise and resources of others including nurse colleagues, team members, pastoral services, hospice specialists and ethics consultants/committees when confronting the complexity of these issues.
- The willingness to consider participation in assisted suicide is generally motivated by mercy, compassion, promotion of patient autonomy and quality of life considerations. It is recognized that the nurse's views about participation in assisted suicide may be different than the official position of the nursing profession. Regardless of the opinion of the nurse, it is a breach of the ethical traditions of nursing, and the Code for Nurses, to participate in assisted suicide.
- The debate and controversy surrounding assisted suicide has highlighted the shortcomings of the health care system, in particular, care of the dying. Nurses and the nursing profession can take an active stance to create health care environments that provide humane care.
- Advance the precepts of Nursing's Agenda for Health Care Reform, one of which calls for careful assessment of the "appropriateness of providing high-tech curative medical care to those who simply require comfort, relief from pain, supportive care or peaceful death."
- Engage in professional and public dialogue and decision making around assisted suicide. Encourage the participation of nurses in discussions of this issue at the local, state and national level.
- Collaborate with other members of the health professions and citizens to advance and ensure the availability of quality end-of-life care.
- Provide education for health professionals and the community on ethical and legal rights and responsibilities surrounding health care decision making, treatment options, pain control, symptom management and palliative care.
- Support the use of outcome measurements and further research to ensure more scientifically based, responsible and ethically sensitive end-of-life treatment.
- Advocate for the removal of barriers to the delivery of appropriate end-of-life care through legislation and changes in restrictive regulatory and institutional practices.
- Promote patient and family participation in treatment decision making and the use of advance directives.
Nurses need to remain in the forefront as leaders and advocates for the delivery of dignified and humane end-of-life care. Nurses are obliged to provide relief of suffering, comfort and when possible a death that is congruent with the values and desires of the dying person. Yet, nurses must uphold the ethical mandates of the profession and not participate in assisted suicide. Knowledge of the ethical foundations and parameters of professional practice provides guidance and support to nurses both individually and collectively. Such an undertaking will better prepare nurses to deal with the difficult moral and professional challenges surrounding the issue of assisted suicide.
- American Nurses Association (1992). Nursing's Agenda for Health Care Reform. Washington, D.C: The Author.
- American Nurses Association (1985). Code for Nurses with Interpretive Statements. Kansas City, MO: The Author.
- American Nurses Association (1980). Nursing: A Social Policy Statement. Kansas City, MO: The Author.
- American Nurses Association (1992). Compendium of Position Statements on the Nurse's Role in End-of-Life Decisions. Washington, DC: The Author.
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