TAKING A STANCE ON PHYSICIAN AID IN DYING Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN Palliative Care Specialist Director of Professional Practice, HPNA Consultant, CAPC Palliative NP, NSMC Disclosures No financial disclosures or conflict of interest Objectives Describe the process of organizational review of PAD/PAS Discuss challenges of hospice and palliative care where PAD/PAS is legal Note - This session will not discuss whether PAD/PAS is right or wrong. Rather the goal is to move the conversation to supporting clinicians in states where it is legal. 1
Historical Experience with PAS/PAD Clinical and administrative role in a Oregon hospice when Death with Dignity legislation first went to vote As Vice president for the Oregon Hospice Association had to make a statement regarding organization position on law As a hospice coordinator for a community hospital to draft an organizational response Exposed to different perspectives and Worked with AAHPM, NHPCO on 2016 a forum on aid in dying Revised the HPNA Position Statement on PAD/PAS, 2017 Case Example You are referred a 55 year-old female, Mary, with a recent diagnosis of ALS. She and her family are devastated by the diagnosis. You discuss goals of care and advanced care planning. You learn she is fiercely independent and does not want to lose her dignity. Mary tells you that when she must be dependent on BiPAP and a trach, she wants to end her life. You discuss all the things palliative care can provide symptom management, psychosocial/emotional/spiritual care, and continuity of care. She seems relieved, agrees to care, and she becomes part of your panel for 1.5 yrs. You continue to have discussions about quality of life and it seems good. Then she needs BiPAP 12 hrs. a day and there is discussion of her trach being used not just for medications but for tube feeds. Mary now tells you she wants to implement a plan for assisted death. You live in Montana or Vermont, where there are no guidelines. What do you do? Quick Review States where PAD/PAS is Legal 1994 Oregon Ballot Measure 16 Death with Dignity Act passed Injunction until 1997 2008 Washington, On the Ballot in and passed The original ground zero as legislation was introduced in 1991 2009 Montana Supreme Court decision "nothing in Montana Supreme Court precedent or Montana statutes indicating that physician aid in dying is against public policy. 2013- Vermont Legislature passed the Act 39 Patient Choice and Control at End of Life Act. First state to pass through legislature 2014 New Mexico initially allowed PAD/PAS but decision was overturned in 2015. 2015 - California passed the End of Life Option Act, which went into effect from June 9, 2016 2016 - Colorado voters passed Proposition 106 End of Life Option Act 2017 District of Columbia passed Death with Dignity Act 2
Language Matters Medical Aid in Dying v. Assisted Death v. Assisted Suicide v. Self Determined Death Suicide is a stigmatized term that refers to someone taking their own lives after struggling with mental illness. The role of the health care professional RN vs. APRN, MD/DO vs. PA, SW, Pharmacist, Chaplain Conscientious objection versus abandonment Education about palliative care versus participation Support of professionals in states where it is legal Terms and definitions To discuss the issue need clarity of the issues Physician-assisted suicide Physician aid in dying Physician-assisted death Hastened Death Be clear about not focusing on- Voluntary active euthanasia or mercy killing Involuntary active euthanasia or murder Palliative or Terminal sedation Withdrawal or Withholding of technology Voluntary Cessation of Eating and Drinking The vast spectrum of palliative care services International practices and religious organizations Opposing Organizations American Medical Association American Nurses Association National Hospice and Palliative Care Organization 3
ANA Code of Ethics for Nurses The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. The nurse respects the patient s right to self-determination. Nurses assist patients with decisions about resuscitation status, withholding and withdrawing lifesustaining therapies, forgoing nutrition and hydration, palliative care, and advanced directives. The nurse should provide interventions to relieve pain and symptoms in the dying patient with respect to evidence-based palliative care practice standards and may not act with the sole intent to end life. ANA 2015, p.3 ANA on Euthanasia, Assisted Suicide, and Aid in Dying The American Nurses Association prohibits nurses participation in assisted suicide and euthanasia because these acts are in direct violation of Code of Ethics for Nurses with Interpretive Statements, the ethical traditions and goals of the profession, and its covenant with society. Nurses have an obligation to provide humane, comprehensive, and compassionate care that respects the rights of patients but upholds the standards of the profession in the presence of chronic, debilitating illness and at end-of-life. ANA Position Statement Euthanasia, Assisted Suicide, and Aid in Dying. 2013. American Medical Association Code of Ethics for Physicians 5.7 Physician-Assisted Suicide Physician-assisted suicide occurs when a physician facilitates a patient s death by providing the necessary means and/or information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide). It is understandable, though tragic, that some patients in extreme duress such as those suffering from a terminal, painful, debilitating illness may come to decide that death is preferable to life. However, permitting physicians to engage in assisted suicide would ultimately cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician s role as healer, would be difficult or impossible to control, and would pose serious societal risks. Instead of engaging in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life. Physicians: (a) Should not abandon a patient once it is determined that cure is impossible. (b) Must respect patient autonomy. (c) Must provide good communication and emotional support. (d) Must provide appropriate comfort care and adequate pain control. AMA Principles of Medical Ethics: I,IV 2016. 4
Supportive Organizations Compassion & Choices in Dying Death with Dignity American College of Legal Medicine American Medical Student Association American Public Health Association National Association of Social Workers National Association of Social Workers (NASW) POLICY STATEMENT NASW promotes respect for dignity, quality of life, and self-determination, as defined by each person approaching the end of life. Accordingly, NASW supports legislation, policies, practices, programs, regulations, and research that promote the following principles and goals related to clients end-of-life decision making and care: consumer education and health care provider communication about the full range of options for end-of-life care and the potential benefits and risks associated with each option clients ability to exercise the full range of legally available options as the end of life approaches Neutral Organizations American Academy of Hospice and Palliative Medicine Hospice and Palliative Nurses Association American Psychological Association American Pharmacists Association 5
Ethics Patient autonomy Nonabandonment Integrity Beneficence Nonmaleficence What is an organization to do? Members of the organization Who are they? What is the mission? No matter what essential to address moral distress Challenge is to keep the conversation neutral and nonblaming Considerations for professionals Education about hastening death Ethical principles; Legislation around assisted death and its implication; Code of Ethics for various disciplines Practice Assessment and understanding the difference between actual desire for hastened death versus unmanaged symptoms Moral Distress, Policy Participation in policy about assisted death as it affects State Laws vs. Federal Law vs. Professional Standards Nursing Social work Chaplaincy Pharmacist 6
Thank you-- Thoughts and Comments Reference and Resource List Available online 7
Physician Assisted Death Resources Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN Practical Aspects of Palliative Care Thursday September 14, 2017 Boston, MA References and Resources Professional Organizations American Medical Association. Code of Ethics. CHAPTER 5: OPINIONS ON CARING FOR PATIENTS AT THE END OF LIFE. 2016. https://www.ama-assn.org/sites/default/files/mediabrowser/code-of-medical-ethics-chapter-5.pdf. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association; 2015. Position Statement Euthanasia, Assisted Suicide, and Aid in Dying. 2013; http://www.nursingworld.org/mainmenucategories/ethicsstandards/ethics- Position-Statements/Euthanasia-Assisted-Suicide-and-Aid-in-Dying.pdf. Position Statement - Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions. 2012; http://www.nursingworld.org/mainmenucategories/ethicsstandards/ethics- Position-Statements.aspx Position Statement - Registered Nurses Roles and Responsibilities in Providing Expert Care and Counseling at the End of Life. 2010; http://www.nursingworld.org/mainmenucategories/ethicsstandards/ethics- Position-Statements/etpain14426.pdf. American Society of Healthsystem Pharmacists. 2103. ASHP Statement on Pharmacist s Decision-making on Assisted Suicide. Ethics Statement. https://www.ashp.org/-/media/assets/policyguidelines/docs/statements-pharmacists-decision-making-assistedsuicide.ashx?la=en Accessed August 17, 2017. Professional Hospice and Palliative Care Organizations American Academy of Hospice and Palliative Medicine. Advisory Brief. 2015. http://aahpm.org/positions/padbrief Accessed January 2, 2017
Statement on Physician-Assisted Dying. 2016. http://aahpm.org/positions/pad Hospice and Palliative Nurses Association. Physician Assisted Death/Physician Assisted Suicide. Position Statement.2017. http://advancingexpertcare.org/wp-content/uploads/2017/07/physician-assisted- Death-Physician-Assisted-Suicide.pdf Guidelines for the Role of the Registered Nurse and Advanced Practice Registered Nurse When Hastened Death is Requested. 2017.http://advancingexpertcare.org/wp-content/uploads/2017/07/Guidelines-for- RN-and-APRN-When-Hastened-Death-Requested.pdf Accessed August 19, 2017. National Hospice and Palliative Care Organization. Commentary and resolution on physician assisted suicide. http://www.nhpco.org/sites/default/files/public/pas_resolution_commentary.pdf Organizations Promoting Aid in Dying Compassion & Choices in Dying https://www.compassionandchoices.org Accessed August 20, 2017. Death with Dignity https://www.deathwithdignity.org Accessed August 20, 2017 State Legislation Oregon. Department of Human Services. Oregon Death with Dignity Act. http://public.health.oregon.gov/providerpartnerresources/evaluationresearch/d eathwithdignityact/pages/index.aspxwww.oregon.gov/dhs/ph/pas/index.shtml, Washington. State Department of Health. Death with Dignity Act. www.doh.wa.gov/youandyourfamily/illnessanddisease/deathwithdignityact. Accessed August 19, 2017..
Vermont. Patient Choice and Control at End of Life Act. 2013. www.healthvermont.gov/systems/patient-choice-and-control-end-life. Accessed August 19, 2017. Montana. Death with Dignity Act. http://leg.mt.gov/bills/2015/billpdf/sb0202.pdf. California. End of Life Option Act. https://leginfo.legislature.ca.gov/faces/billnavclient.xhtml?bill_id=201520160sb1 28. Colorado. Proposition 106 Access to Medical Aid-in-Dying Medication. http://www.leg.state.co.us/lcs/initiative%20referendum/1516initrefr.nsf/b74b3fc 5d676cdc987257ad8005bce6a/99fbc3387156ab5c87257fae00748890/$FILE/20 15-2016%20145bb.pdf. August 19, 2017. Washington, DC. Death with Dignity http://lims.dccouncil.us/download/33261/b21-0038- Introduction.pdf. August 19, 2017..