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Introduction   

An inevitable part of life is death, and nurses are often exposed to this reality more often than most. In the United States, end-of-life care has undergone many changes in recent decades, though it raises some ethical considerations. For example, what role do nurses play if a terminal patient wishes to end their life? What is considered within the nurse’s scope of practice, and what do professional nursing organizations say about this topic?

Medical aid in dying (MAiD) is legal in only 10 states currently, but more legislation is in progress (1,4,8). To this end, nurses should be familiar with end-of-life concepts, including their own feelings about death, as well as caring for the dying patient.

Definition of Terms 

As with other types of nursing, defining key terms is important to facilitate a good understanding of concepts and discussions. Even within the medical and nursing communities, the definitions of these terms vary, particularly because of the delicate nature of the topic. For the purpose of this course, they will be defined as follows:  

Medical Aid in Dying (MAiD) or Physician-Assisted Dying (PAD) – refers to a practice where a physician writes a prescription for a lethal dose of a drug at the request of a competent adult patient with a terminal illness whose life expectancy is 6 months or less (1, 2, 3).  

It provides a mentally capable adult with the option of ending their life on their own terms, by ingesting a medication that will allow them to die peacefully (1). The patient does not ever need to take the medication, but will have it on hand, and a physician does not have to prescribe this medication if they feel ethically or morally opposed (2).  

Some organizations differ in their agreement about whether MAiD and PAD are synonymous; the American Academy of Hospice and Palliative Medicine state that they are, whereas entities such as Compassion & Choices believe that they are separate acts (1, 3). Either way, MAiD, and PAD both aim to give patients a final act of autonomy in determining the conditions of their death (1, 2, 3).  

Euthanasia and Assisted Suicide – is the intentional act of someone, other than the patient, administering a lethal dose of a drug to hasten a peaceful death.  

The main difference between this and MAiD or PAD is who administers the medication, as the end goals are the same (1). Euthanasia is currently illegal in all parts of the United States.  

As discussed above, some consider MAiD, PAD, euthanasia, and assisted suicide to embody the same concept. However, many professional organizations take issue with the use of the terms, “suicide” or “assisted suicide”, in this process.  

The American Academy of Family Physicians, American Academy of Hospice and Palliative Medicine, American Medical Women’s Association, and the American Public Health Association all have policies rejecting the use of these terms to describe the practice of medical aid in dying (4). The American Nurses’ Association also rejects that euthanasia and medical aid in dying are the same concept (5).  

End-of-Life Care – refers to the holistic medical and supportive care given during the time surrounding death (6, 11). End-of-life care involves the patient and their family unit, which some organizations describe as anyone “linked by biology or affection; family is whoever the patient says it is” (11, 12).  

It encompasses palliative care, which aims to enhance a person’s quality of life by providing symptom relief at any stage in illness. (7). Furthermore, the earlier on in a disease process palliative care is given, the better; this increases the patient’s overall quality of life.  

End-of-life care also includes the completion and gathering of legal documents, like an advance directive, a last will and testament, and any funeral and burial/cremation plans. It also may include spiritual care, pain management, family counseling, and more. The nurse is often one of the key members of the healthcare team providing or facilitating these types of services.

ANA Position Statement: Medical Aid in Dying 

The American Nurses’ Association (ANA) has a position statement entitled, “The Nurse’s Role When a Patient Requests Medical Aid in Dying” (5). In this statement, the ANA declares that high-quality end-of-life care includes nonjudgmental support for dying patients, as well as a vested interest in the patient’s right to self-determination (5).  

The ANA recognizes the nuance in a topic so controversial at this one, though maintains that nurses have an ethical responsibility to be knowledgeable about the subject, as well as their own personal feelings surrounding death and dying.  

Other key points in the ANA’s statement include:  

• Nurses are expressly prohibited from administering any medical aid in dying (MAiD) medication  

• There is a need for objectivity when discussing MAiD with patients  

• Nurses should feel comfortable discussing all end-of-life options with their patients 

• The nurse understands that the patient is the one who self-administers the MAiD medication, and no one else  

• Part of nursing care is providing the alleviation of suffering, but not to directly end life  

• The nurse may be requested by the patient to be present at the time that they take the life-ending medication; the nurse may refuse or may accept, and should consider their position before this situation arises 

• Any nurse has the right to conscientiously object to being involved in the MAiD process, though the nurse: 

• • Must not abandon the patient  

• • Must not refuse to provide basic comfort and safety measures 

• • Must inform employers, if MAiD is anticipated and legal, that they do not wish to be involved in this process 

• While providing palliative care, the nurse should help with the alleviation of pain and other symptoms, but may not act with the sole intent to end life 

History and Background 

Throughout human history, there has always been disease, suffering and death. For millennia, there has been debate over the role of suicide, euthanasia, and quality of life in many societies, as well as what a physician’s role in the matter should be (9). With the advent of modern medicine, lifespans are markedly longer, and overall health and quality of life are substantially higher in industrialized countries than even 100 years ago.  

In the 1960s, the hospice movement was brought to the United States from England, and Elizabeth Kubler-Ross identified the five stages a terminally ill patient typically progresses through as they approach their death (14). In the 1970s, the notion of death with dignity made it all the way to the US Senate Special Committee on Aging (14). During the 1990s, the growing end-of-life movement focused national attention on death and dying, including the need for increased physician education and public awareness (14).  

In the 2000s, many organizations published materials and created initiatives to address end-of-life care; the Terri Schiavo case brings advance directives to the forefront of the national conversation (14). Additionally, ever more conversations are developing over end-of-life care, including the right of a terminally ill person to end their life on their own terms. 

Brief Overview of State Legislation 

Within North America, much of the current legislation surrounding MAiD has only developed in the past few decades. In 1989, Oregon introduced the first-ever assisted dying bill in the United States (10). California and Washington State followed suit, and in 1994, Ballot Measure 16 passed in Oregon, also known as the Death with Dignity Act.  

Despite a temporary restraining order against the bill, the Death with Dignity Act officially took effect in 1997. Washington State passed their law in 2008, followed by Vermont in 2013, California in 2015, and then five more jurisdictions in subsequent years: Colorado, Washington, D.C., Hawaii, New Jersey, Maine, and New Mexico (10).  

Thus, at the time of the writing of this article, 10 states and Washington, D.C. have legalized the Death with Dignity Act (1, 8, 10).

Clinical Criteria 

All states within the US that currently allow MAiD to have strict criteria that must be met.  

These include, but are not limited to, the following  

• Must be an adult, defined as 18 years of age or older. 

• Live in a state where MAiD is legal. 

• Have full mental capacity to make one’s own healthcare decisions and be able to communicate these wishes. 

• Have a terminal illness with a prognosis of six months or left to live; at least two physicians must agree on this, as well as the eligibility for MAiD. 

• Make two verbal and one written request for MAiD and have a private conversation with their own primary care physician.  

• Be able to self-administer the medication (in this case, swallowing pills). 

(1, 13) 

Additionally, most states have additional considerations and safeguards in place, including: 

• A patient’s request for MAiD must be evaluated quickly by a physician.  

• The patient must be informed by the prescribing physician must inform the person. requesting the medication that once they have the medication, they never have to take it and can decide to change their mind at any time.  

• Some states require a 15-day waiting period for the first request of MAiD and receiving the prescription. 

• The physician must ensure informed consent of the patient.  

• The physician must inform the patient of all end-of-life options, including hospice and palliative care, pain control, and comfort care.  

• The individual must have the right to rescind their request at any time.  

(1,17) 

Nursing Implications 

As discussed throughout this course, the nurse has many roles when it comes to end-of-life care. In particular, nurses in the following areas will likely have the most exposure to this topic: ICU, ER, PACU, hospice, geriatric care, skilled nursing facilities, home health care, and medical-surgical inpatient units. As patient acuity has been increasing in all nursing areas in recent years, it is likely that most nurses will encounter end-of-life care at some point in their career (15). Thus, nurses should be prepared to have discussions with patients about their final wishes, as well as knowing what type of care is appropriate for each terminally ill patient.  

Examining One’s Own Beliefs and Attitudes 

Much of the nursing care needed for patients who are dying requires first that the nurse examine their own perspectives on death. In fact, the American Nurses’ Association has a position statement entitled “Nurses’ Roles and Responsibilities in Providing Care and Support at the End of Life” (12). This statement is distinct from the ANA’s position on the nurse’s role in MAiD, and includes some of the following competencies that apply to all nurses (5):  

• Have basic knowledge of palliative nursing care. 

• Be comfortable having discussions with patients about death and dying 

• Collaborate with care teams to ensure that information about a patient’s impending death is accurately portrayed to the patient and their loved ones  

Providing Compassionate End-of-Life Care 

When with a patient at the end of their life, here are some things the nurse can do to ensure compassionate care (11,12, 16):  

• Promote comfort and relief of pain/other stressful symptoms 

• Support the patient, their family, and others close to them  

• Contribute to conversations about end-of-life preferences and involve the healthcare team as necessary and appropriate  

• Recognize that a patient’s well-being encompasses not only physical comfort, but also spiritual, psychological, and interpersonal dimensions  

• Advocate for the patient’s last wishes to the best of the nurse’s ability and scope of practice  

• Provide for a peaceful, dignified death that is as pain-free as possible  

Emotional Support Resources for Nurses, Patients, and Families 

Though the topic of death and dying can be difficult for anyone, it may be particularly challenging for nurses, who are part of a profession with a high exposure to end-of-life issues. Fortunately, there are myriad resources for nurses who need emotional support for coping with death. Some of these include:  

• For immediate help with mental health, the Substance Abuse and Mental Health Services Administration (SAMHSA) is available here: https://www.samhsa.gov/find-help/national-helpline  

• The Emotional PPE Project strives to provide mental and emotional care to those working in the healthcare field: https://emotionalppe.org/  

• Most employers have an Employee Assistance Program (EAP) that includes free counseling and other mental health services.  

• Many articles on Grief, Bereavement, and Coping exist online, such as this one from the National Cancer Institute: https://www.cancer.gov/about-cancer/advanced-cancer/caregivers/planning/bereavement-hp-pdq  

• If you are a caregiver of a patient on hospice, counseling is available to you as well for up to a year after the patient’s death. Contact the specific hospice for further details.  

• The Conversation Project aims to help everyone talk about and solidify their wishes for the end of their lives. Their many printable resources and conversation starters are available at https://theconversationproject.org/  

Conclusion

Nowadays, the human lifespan is substantially longer than it was even a century ago. End-of-life care and topics on medical aid in dying have come to the forefront among healthcare providers, as well as the general public. Currently, 10 states and the District of Columbia have Medical Aid in Dying laws with which nurses should be familiar.

It is crucial for nurses to examine their own views on death and dying, and to feel comfortable talking about this subject with their patients. As patient autonomy becomes a more prominent feature of healthcare, so does discussing the final wishes patients have for their last days of life.

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