Hospice and Assisted Suicide

[Spidey's mom, ADN, BSN, RN]

Those hospice nurses living in states where assisted suicide is illegal, how do your hospices handle patient and family admitting to assisted suicide plans with the means to do so?

Leaving OUT your own personal belief system, what are the legal ramifications for hospice knowing ahead of time and therefore becoming complicit in the act? If the legal system charges the spouse, can we be held liable? Are we not mandated reporters in this situation? Or do we handle it within the system of the ID team?

How do your hospices manage this patient?

I found the following from Oregon where assisted suicide is legal.

http://www.cbc-network.org/2010/10/oregon-hospices-right-not-to-cooperate-with-assisted-suicide/

I hope the actual reason is more fundamental, that hospice workers in Oregon understand that facilitating assisted suicide is directly contrary to the hospice philosophy. Indeed, rather than facilitating doctor-prescribed death, hospice professionals are supposed to prevent the suicides of their patients by intervening to provide services or treatments the patient might be lacking, so that they no longer want to die immediately.I can personally attest to how seriously this obligation is taken by hospice administrators. I was trained as a hospice volunteer, and I was told in no uncertain terms that if I even suspected that a patient was suicidal, I was to immediately inform the multidisciplinary team so they could provide preventive mental health and other services—just as medicine would for any other suicidal person.This raises an important question: Why does hospice philosophy oppose assisted suicide? According to the late Dame Cecily Saunders—the creator of the modern hospice concept and one of the great medical humanitarians of the 20th Century—doctor-prescribed suicide denies the equal dignity of hospice patients. As she wrote in the 2002 book, The Case Against Assisted Suicide (chapter, “The Hospice Perspective”), hospice asserts on behalf of the dying patient his or her “common humanity and personal importance” to the moment of natural death.The great American hospice physician, Ira Byock, is similarly opposed to assisted suicide, writing in the Journal of Palliative Care, “The hospice focus is on life and the alleviation of suffering,” whereas “the goal of assisted suicide and euthanasia is death.” Moreover, if a hospice cooperated in doctor-prescribed death, it would abandon that patient to his or her worst fears—that they will die in agony, that they are a burden, that their lives truly are no longer worth living.Thus, when assisted suicide facilitators in Oregon brag that they have assisted the suicides of hospice patients, they are actually admitting that they interfered with the proper medical care of these patients. Indeed, boasting of helping hospice patients kill themselves is akin to patting themselves on the back for helping the patient die after denying them proper pain control—another crucial hospice medical service.This is the bottom line: Hemlock (if you will) and Hospice cannot occupy the same philosophical space. That is why I am very pleased that Oregon hospices are generally keeping assisted suicide at arm’s length. Legal or not, doctor-prescribed death has no place in proper end-of-life care.CBC Special consultant Wesley J. Smith is also a senior fellow in The Discovery Institute’s Center on Human Exceptionalism and a lawyer for the International Task Force on Euthanasia and Assisted Suicide.

[SuesquatchRN, BSN, RN]

My beliefs about assisted suicide have become more nuanced since joining hospice. I now believe that the desire to die is the result of symptoms not being managed - most notably intractable NV and pain. Also, though, the only person who raised the issue with me had ample meds on hand had it been a real wish. I took it, instead, as a plea to get her comfortable.

I have never lived in a state in which as was legal so have no idea about how I would broach it then. But I would be uncomfortable, and would, as I did with the aforementioned patient, strike a bargain to give us x time to get the symptoms controlled and then we could discuss it again.

[Spidey's mom, ADN, BSN, RN]

My beliefs about assisted suicide have become more nuanced since joining hospice. I now believe that the desire to die is the result of symptoms not being managed - most notably intractable NV and pain. Also, though, the only person who raised the issue with me had ample meds on hand had it been a real wish. I took it, instead, as a plea to get her comfortable.

I have never lived in a state in which as was legal so have no idea about how I would broach it then. But I would be uncomfortable, and would, as I did with the aforementioned patient, strike a bargain to give us x time to get the symptoms controlled and then we could discuss it again.

Thanks. I added the link about Oregon because I thought it interesting that even in a state where it is legal, hospice should not be involved.

I agree that symptoms are not being managed - but those symptoms can be more than physical pain, nausea, vomiting. It can be emotional. Fear of the way they might die. Like suffocation.

That fear, in my opinion, needs to be managed as well.

My biggest question is, having knowledge ahead of time, are we liable?

[SuesquatchRN, BSN, RN]

Beats me.

[leslie :-D]

Thanks. I added the link about Oregon because I thought it interesting that even in a state where it is illegal, hospice should not be involved.

I agree that symptoms are not being managed - but those symptoms can be more than physical pain, nausea, vomiting. It can be emotional. Fear of the way they might die. Like suffocation.

That fear, in my opinion, needs to be managed as well.

My biggest question is, having knowledge ahead of time, are we liable?

there isn't any federal law regarding this - it is a state issue and ea state handles it case by case.

it has been my experience that if hospice didn't fully try to explore any/all underlying issues, and respond accordingly, they could be held legally and financially liable, if not adhering to the poc.

the hospice team should be addressing every aspect of this pt's pain...

as you stated, his emotional/mental pain, as well as his physical pain.

it is 'assumed' that he is depressed, and so, is not acting competently or with full autonomy.

here are a couple of the most relevant links i could find...which again, is difficult, considering there are so many ethical considerations and gray areas.

http://www.eperc.mcw.edu/fastFact/ff_210.htm

http://www.eperc.mcw.edu/fastFact/ff_156.htm

what does your med'l director say?

or the social worker?

sounds like a stat psych consult may be necessary?

some sort of more aggressive tx is definitely indicated.

the bottom line is, you want it to be well documented, that hospice indeed, did everything they could to get to the root of this pt's despair.

i'm sorry steph.

that's a tough and tragic situation.

i pray your pt finds comfort.

leslie

[leslie :-D]

...and another aspect i was thinking of.

even where pas is legal, the pt still needs to go through extensive testing before s/he is deemed qualified to 'die'.

the state wants to ensure pt is competent and fully aware of implications set forth.

and so, for your hospice to have a vulnerable pt., it would seem to me that they (hospice) should be doing everything possible to prevent this...for now...

after pt has been thoroughly evaluated, with other interventions applied.

of course you know to write meticulous notes...

even conversations you've had with other members of the team.

that's all, i'll shut up now.:)

leslie

eta: oops..one more thought: call your state nurse's association.

they have an ethics/legal dept...and have been an excellent resource for me in the past.

[ErinS, BSN, RN]

I know you didn't want personal opinions, but I am going to give mine. First, people rarely commit suicide because of physical pain. Suicide is usually because of emotional pain. I don't know what the hospice role should be in assisted suicide, but I know one of my patient's killed himself and there are others I have suspected. The one who killed himself was well managed symptom wise. He killed himself after I described the dying process where he would slip into a coma. I can't be sure, but I think the thought of losing his independence and that his family would have to go through watching him die. He shot himself. You are going to have a real hard time convincing me that assisted suicide would not have been less traumatic than his wife finding him in their living room, and giving him the option of assisted suicide would not have provided him some dignity.

My last thought on assisted suicide: I get to meet incredible people through my work. Individuals with a quiet strength, calm dignity, and an amazing hope for their life that is left. I am not sure, knowing what I know, that I could be diagnosed with end stage CHF, for example, and know about the swelling, the leg sores, the dyspnea, the anxiety, the slow crippling debility that will leave me dependent on my kids or husband to help me to the toilet, and just keep going on. I fear I am not that strong, not that brave, not that hopeful. I suspect if I received a terminal diagnosis, I would spend all my money on a lavish vacation, say good bye to my family, and then choose my own death before it got me.

I work for a hospice that does not and I believe will never provide assisted suicide support. I am blessed in my work, and I do not share these opinions with my patients. I screen for suicide risk and manage symptoms the best I can, working with the IDT. But the longer I work in hospice the more sure I am that assisted suicide should be an option, if only to allow some dignity and relief from truly intractable suffering.

[FLArn]

My understanding of Florida regulations is as follows: Any expressed plans must be reported to the MD and SW for follow up. If staff is present during the attempt of execution of a plan the EMS system must be activated regardless of code status. If staff happens upon the patient after the plan has been implemented (e.g. meds have already been ingested) and the patient is a DNR, no intervention is required and the patients EOL advance directives are followed. If the patient is not a DNR the EMS system is activated.

[Spidey's mom, ADN, BSN, RN]

Thanks FLArn. :hug:

[Alvindudley]

This is really well put. As a hospice nurse, if I do my job well and teach effectively, not only am I able to mitigate the pain and suffering at EOL but also empower my patients to make the best decisions for themselves. I have not yet encountered a suicidal patient but when I do, I hope I handle it with as much grace as you.

[Marshall1]

In Florida, unless it's changed since 2002, if a patient on hospice (or not) is a DNR they have to have a separate DNR for EMS - one of my parents was on hospice in Florida - this is how I know this. We had the DNR but had an additional one that was specifically for EMS that we were told to post where it could easily been seen by everyone - we did that.

The sad thing about the death/dying, besides the obvious loss of a person we love, is in this country we do not want to discuss such matters....people will get on tv and talk about their abuses, affairs, money, you name it, but ask about death/dying/wills almost 100% will say "That's morbid" or " I don't want to talk about it" - trust me, its a conversation worth having.

[malamud69, BSN, RN]

It is each person's individual right to choose their own death. Period end of story. As such, suicide being illegal is an absurdity. All states must enact assisted suicide programs...it is only human. (Remember...separation of church and state...as these absurd laws are based on religious mumbo jumbo) That being said, I applaud the work of hospice organizations...My father and grandfather both died with hospice care and their deaths were as "peaceful" as they could be. To prolong someone's misery, on the other hand, based on lack of paperwork or family bickering as is often the case is cruelty...plain and simple. It is therefore each individuals responsibility...as has been noted...to "get their affairs in order" so as not to be at the mercy of the state/institution/religious zealot etc...Suicide "plans" as many people have them are a must in a society that refuses to honor this most important personal decision. One more thing...to say people that are suffering and at the end of their life that want to end their lives need mental health counseling, is one of the most disgusting and selfish ideas put forth...