An experienced hospice nurse and I sat on the terrace of a woman who'd been battling multiple myeloma for years. This elderly patient had invited us to her home to discuss something important. Frail, but sitting very tall, she said, "I want to know how I can hasten my own dying if my suffering becomes too much for me to bear." The hospice nurse immediately pushed herself away from the table, saying firmly, "I can't help you with that." I leaned toward the patient and said, "I can."
This nurse's response wasn't unusual, as I know from my research and from years of experience as a clinical coordinator for Compassion and Choices, an end-of-life advocacy organization. Many hospice nurses are reluctant to answer patients' questions about legal options for hastening dying. For example, while most hospice nurses will support a patient's informed decision to stop eating and drinking, many won't volunteer such information to a patient who asks and who may not know of the option.
I suspect that many nurses fear unduly influencing vulnerable patients or removing their "hope." But while nurses should always explore the meaning behind a patient's request for information about hastening dying, they must also listen, respectfully and without judgment, to patients' concerns about their dying. Unfortunately, terminally ill patients who are too candid about their wish to hasten death may risk being reported for "suicidal ideation." Some patients have told me that they've been committed involuntarily to a psychiatric hospital or placed on a suicide watch for "saying the wrong thing" to a nurse or social worker. Others have said that when they ask what they can do "to end this," some hospice nurses mechanically repeat the hospice movement's credo, "We neither hasten nor prolong dying." Such patients quickly learn what not to say.
In 1994 the American Nurses Association (ANA) confirmed that nurses shouldn't "[make] the means of suicide ([such as] providing pills or a weapon) available to a patient with knowledge of the patient's intention." But the ANA did not include taking appropriate palliative measures in its definition of assisted suicide.
Nurses who care for terminally ill patients must be encouraged to inform patients who ask about all legally and ethically sound palliative options, including those that might hasten dying: forgoing life-prolonging interventions, refusing food and fluids, and receiving high doses of opioids or palliative sedation that causes unconsciousness. When terminally ill, suffering patients use such legal means to hasten their dying, they aren't committing suicide. Nurses who provide information on or support such choices aren't assisting in suicide.
But nurses still must intervene to prevent irrational suicidal acts made by patients suffering from mental illness (particularly depression) or impulsive acts of self-destructive behavior that may be driven by despair, guilt, or hopelessness. Patients suffering from acute or chronic mental illness that interferes with their ability to make informed decisions and who aren't terminally ill but want to die are not the same as competent patients suffering from a terminal illness who seek to hasten dying. Both groups of patients are suffering and need help: different kinds of help.
Often, good palliative or hospice care alleviates the suffering of the dying. Nonetheless, a small but significant proportion of dying patients suffer intolerably. Although most don't seek a hastened death, some will ask about it. And when they do, nurses experience a great moral conflict: they want to help their patients die well, yet they don't want responsibility for helping them to die.
Patients who are dying have no control over the inevitability of their death. When they suffer intractable symptoms, they should receive complete end-of-life support from nurses. It's the least we can provide.