Question

What are the professional and personal responsibilities of the nurse related to the Euthanasia? Professionally what is expected of you when an ethical dilemma such as this arises when a patient is in your care. Personally, from an ethical perspective, how would you manage this ethical dilemma as it relates to your personal feelings and concerns.

Answer 1

Nurses’ Roles in Euthanasia
Nurses are not the one conducting euthanasia, but they are involved in the process which begins when the patient requests for euthanasia and ends with providing support to the patient’s relatives and healthcare colleagues after the act. It is vital for nurses to know their role during the process. Nurses should be open-minded and non-judgmental to accept the euthanasia request as nurses’ professional attitude could discourage patient from euthanasia. Nurses’ role in euthanasia can be divided into three phases.

Phase I: Pre-Euthanasia
This is the initial phase of euthanasia from receiving a euthanasia request to sign a written consent. It will be consisted of assessment, consultation and written consent during this phase.

Assessment
Nurses should listen to the patient carefully, to assess the underlying reasons for requesting euthanasia and the factors contributing to the decision. Improper requests which originate from relievable suffering should be withdrawn and provide alternative methods for the patient to avoid undignified deaths. Also, patients should be assessed the knowledge regarding his or her medical diagnosis, condition, prognosis and other available alternatives. Then, general condition such as physical examination, severity of illness and predictable deteriorated condition of the patients should be assessed to ensure that patient fulfills the criteria of conducting euthanasia. Patient’s family is also involved to assess their reaction on the request of euthanasia, allow heartfelt communication between patient and family members, encourage ventilation.Hence, nurses should be sensitive and maintain professional manner when conducting assessment.

Consultation
As mentioned in the condition, mutual agreement of a panel of experts is needed to proceed to euthanasia. This committees include clinical psychologists, social workers, nurses and doctors.

Written Consent
Consent should be signed in a quiet room to ensure a nondisturbing environment. Nurses then explains the consent with non-threatening tone and allow time for questions. It is important for nurses to make ensure the patient and family completely understand the process of euthanasia, potential discomfort during the administration and patient right before the signature of written consent.

Phase II: Intra-Euthanasia
This is the implementation phase of euthanasia from preparing the patient and medication to administering euthanasia. It should be conducted in a special room to provide peaceful environment for promoting human right of die with dignity and minimizing disturbance of the procedures.

Preparation
Firstly, intravenous access is set on the patient for injecting medication. Secondly, procedure would be explained again to the patient and family members and reassure that nurses will present in the process and give support to relieve their anxiety. Thirdly, nurses assist in preparing medication including sedative agent, analgesic agent and euthanatics and label them properly. An intravenous premedication like midazolam can be administered first to induce a light sleep if the patient does not wish to be aware of the moment of coma induction.

Assistance
Emergency set should be prepared by nurses and used only under the instruction in protocol. Also, Nurses should offer emotional support to family members if they present in the procedures.

Record
To evaluate the procedure, nurses should keep a record of all used medication, and involved situations and person. The forms including signed consent forms, pain assessment form, record of euthanasia and last office chart should be charted clearly. The record of euthanasia is similar to the record of operation theatre which needed to record the date and time, place of the procedure, healthcare professionals involved and ranks, the intravenous injection site and all given medication.

Phase III: Post-Euthanasia
This is the last phase of euthanasia from certifying death of patient to supporting patient’s family. After the doctors certified the death, nurses can explain to family about the cease of euthanasia and proceed to the last office procedure. Even though the decision is deliberately made, grieving process and feelings of guilt in family members may rise. Emotional support like giving reassurance and listening to their feelings should be provided to them. It requires good communication skills and counselling skills in nurses. Timely referral to counsellor is beneficial for family whose emotion is uncontrolled. In addition, all unused euthanatic agents should return to pharmacy.

Conclusion

​​​​​Euthanasia not only can shift medical resources to other level of care, but also bring benefits to terminally ill patients. There were three phases of carrying out euthanasia, including pre-euthanasia, intra-euthanasia and post-euthanasia. The role of nurses in each phases of euthanasia was emphasized. In the pre-euthanasia phase, nurses must equip with professional assessment skills and communication skills, and act as an advocator to protect patients’ rights. During the intra-euthanasia phase, nurses should assist in preparing medication, monitor the patient’s condition, document properly and provide support to the family members. In the post-euthanasia phase, nurses can provide emotional support to the relatives, make referral if necessary, return the unused agents to pharmacy and fill in incident evaluation form.

When an ethical dilemma such as this arises, we can manage this ethical dilemma as it relates to your personal feelings and concerns by following principles:

1) Withholding/withdrawing of medical interventions
One of the dilemmas that can occur relates to the cessation of medical interventions in patients. Sometimes these interventions range from minor, such as a non-life sustaining medication, to more complex, such as mechanical ventilation. Sometimes life-sustaining therapies may prolong suffering at the cost of decreasing the patient’s quality of life. Patients and their family often decide to stop medical interventions based on some of these factors. This is why advance directives are so important. Advance directives are documents that enable patients to make their decisions about medical care known to their family. If a family member knows for sure that their loved one would not have wanted a particular medical intervention done, it may help to alleviate some of the burden they may feel about making the decision. It also helps prevent the initiation of some life sustaining treatments beforehand, in which case no decision will be need to be made to withdraw that intervention. It also can help reduce overall costs of futile medical care.

2) Do not attempt resuscitation (DNAR)
If a patient has an order for a DNR or DNAR, it means that the patient has elected for cardiopulmonary resuscitation (CPR) to not be initiated or administered in the event of a cardiac arrest. CPR could include the use of chest compressions, cardiac drugs, and the placement of a breathing tube. Electing to have or not to have CPR is a difficult but common medical decision that patients nearing the end of life often make. The success rate of CPR has been low, around 18%, and it is well known that the percentage is even lower among patients with advanced illnesses such as terminal cancer or end stage heart failure. A “do not intubate” (DNI) order often accompanies a DNR order, which states that the patient elects not to be intubated with a breathing tube if they go into cardiac arrest. Chest compressions and the use of cardiac medications could still be used.

3) Allow natural death (AND)
Allow natural death is a more recent terminology some health care institutions have adopted to use instead of the traditional DNR orders. Whereas a DNR order states that no attempts should be made to start CPR in a patient, an AND order states that only comfort measures are taken to manage symptoms related to comfort. An AND order simply allows the patient to remain comfortable while not interfering with the natural dying process.

4)​​​​​​​​​​​Medical order for life sustaining treatment (MOLST)
Sometimes also referred to as physician order to life-sustaining treatment (POLST), these newer forms of advance directives were developed in order to improve the communication of a patient’s wishes about life-sustaining treatments among healthcare providers and settings.

5) Hastening death (Principle of double effect)
The principle of “double effect” refers to some decisions that clinicians have that will produce both desirable and undesirable effects. The medication will reduce the pain but also further reduce the patient’s respiratory rate to a level that is inconsistent with life. In the case of double effect, the nurse or clinician should always consider the intended effect of the intervention.

6) Terminal/palliative sedation
Terminal sedation (more recently called “palliative sedation”) is an intervention used in patients at the end of life, usually as a last effort to relieve suffering. It involves sedating the patient to a point in which refractory symptoms are controlled. The goal is to control symptoms, and the patient is sedated to varying degrees of consciousness to achieve this. The intent is not to cause or hasten death, but rather to relieve suffering that has not responded to any other means.

7) Assisted dying
Assisted dying is defined as “an action in which an individual’s death is intentionally hastened by the administration of a drug or other lethal substance.