Hospices plan how to cope with assisted suicide
Court ruling may return issue to the states
As this issue of Hospice Management Advisor went to press, health providers nationwide were awaiting an imminent ruling on two physician-assisted suicide cases by the U.S. Supreme Court with far-reaching potential to transform how they care for dying patients.
Regardless of how the high court rules, hospices are well-advised to clarify their own staff, board, and agency attitudes and values toward this controversial issue, and develop thoughtful policies specifying how they would respond if physician-assisted suicide became legal in their state.
Legal observers predict that the high court will not find a constitutionally protected right for terminally ill patients to receive a doctor’s assistance in ending their lives. More likely, the court will return the issue to the states to chart their own courses. In some states, that could open a new round of legislative efforts and ballot initiatives by assisted-suicide supporters.
In Oregon, where voter-approved Measure 16 is the only law yet passed to permit assisted suicide, a decision by the Supreme Court could finally clear the last legal barrier to its implementation. However, the state legislature voted in June to send Measure 16 back to the voters for reconsideration in a new referendum in November. That bill’s drafters insist that problems unrealized when Measure 16 first passed, such as the frequent ineffectiveness of lethal oral medications, make its implementation problematic. Assisted suicide supporters call the new bill an insult to voters who approved the initiative in 1994 by requiring them to vote on it again.
But what about the other 49 states? Policies opposing legalized assisted suicide by the Arlington, VA-based National Hospice Organiza-tion (NHO) and many state hospice associations would seem to commit them to participation in the state coalitions that will be formed to oppose new assisted suicide proposals. Hospice’s belief that better attention to pain and symptom management should obviate most of the need for dying patients to seek an end to their suffering has not been well-understood in the public debate. But if physician-assisted suicide is legalized, how will hospices operate in the transformed legal environment?
Oregon hospices establish policies
Hospices in Oregon, which had a head start in grappling with the ethics of this issue, emphasize the importance of an interactive process to clarify agency philosophy and values, and of establishing policies to give direction to hospice staff and volunteers. (See examples of assisted suicide policies from two Oregon hospices, inserted in this issue.) In fact, depending on state adult protective services reporting requirements, hospices may benefit from a policy clarifying how to respond to patient requests for assisted suicide whether legal or not.
"If the Supreme Court says this is a right, hospices will need to get ready quickly," says Connie Holden, RN, MSN, director of Boulder County (CO) Hospice. "Unfortunately, many hospices will spend their time and energy opposing legalization. I think a more appropriate role for hospice is to stay out of that arena but focus instead on providing good palliative care," Holden says. "Our business is about providing good hospice care good symptom management and support assessing, encouraging open exploration of the issues, doing everything possible to eliminate sources of distress. All of that should decrease the number of people" seeking medical deliverance, Holden says.
"Our hospice ethics committee developed guidelines for responding to the patient who expresses interest in assisted suicide, whether it is a legal option or not. Frankly, I think hospices should act in the same fashion either way," Holden says. "My point is that this is going on right now, regardless of what the Supreme Court says. We need to be responding to it and preparing our staff and volunteers." The Boulder hospice’s policy states that patients expressing a desire to hasten their deaths "must be carefully evaluated for unmet needs. Our goal is to create an environment in which patients will feel permission to discuss their thoughts, plans, and fears."
Some hospices’ policies specify that their staff and volunteers cannot provide, deliver, administer, or assist with medications intended for assisted suicide nor will they cover it under the Medicare hospice benefit. But they will continue to provide hospice services to patients, regardless of expressed intent to commit suicide.
Policies also emphasize the need to assess for unmet needs, satisfaction with symptom management, depression, anxiety, fear, anger, family pressures, and spiritual concerns. More than one staff member should participate in these evaluations, while the patient care team and/or ethics committee also can be involved either beforehand to make sure no stone has been left unturned in trying to make the patient’s life tolerable or afterward, to evaluate whether the policy succeeded in preserving the agency’s mission and values.
Another view on suicide and liability
A different approach has been taken by Mid-Willamette Valley Hospice in Salem, OR. The hospice’s CEO, Simon Paquette, MSW, says hospices are naive to think they can stand passively by while a patient takes his or her own life without being drawn into a hornet’s nest of legal, ethical, and professional complications.
As part of the informed consent document signed upon admission to the Mid-Willamette hospice, patients agree to inform the hospice immediately if they enact a written request for a lethal prescription under Measure 16. During the subsequent two-week waiting period, the hospice would explore interventions to relieve symptoms, find alternatives, and process a transfer most likely back to the attending physician. On the day the patient actually takes physical possession of the lethal medication, the hospice will discharge the patient and withdraw its medical services.
Paquette says his agency’s legal counsel informed him that for the hospice to remain involved while the patient actively pursues assisted suicide could be in violation of a law passed by Congress earlier this year banning federal funding for assisted suicide. "The legal liability for remaining in there is tremendous," he adds. "What if the patient starts vomiting? Will the family draw conclusions about what the nurse is doing? How can you distinguish pain and symptom management by the hospice from the effects of taking the medication?" Paquette says.
"My advice to hospice programs is to think this through logically and to consider all the kinds of liability legal, ethical, professional for the family. What is the legal battleground that is likely to ensue?" He also recommends a full interdisciplinary review of agency policy, involving legal counsel and liability insurance perspectives, not just clinicians.
What is an ethical response?
For many hospices, developing a response to the potentiality of legalized assisted suicide will be a time-consuming process, as they seek to balance ethical principles such as hospice’s philosophy of not hastening death with its commitment to facilitating patient autonomy.
Benton Hospice Service in Corvallis, OR, used an approach developed by Oregon Health Decisions to facilitate a wide-ranging discussion of assisted suicide by its entire board of directors, reports executive director Judy List. "I think it’s a procedure hospices have to go through. My conclusion: The process was really important. Yes, you need an end result to the discussion, but just importing one won’t do it."
Other hospices have worked with staff and volunteers to clarify their individual attitudes and beliefs on the issue as a prerequisite to determining a collective agency policy. "We provided education for staff in 14 small group settings. I started each session with a survey adapted from Boulder County Hospice, and then surveyed people at the end to see how their attitudes had changed," says Jeanne Brenneis, STM, Director of the Center for Bioethics for Hospice of Northern Virginian in Arlington. "A lot of people who were neutral beforehand went to one side or another. The whole goal was for people to be educated on the issue." The hospice’s board decided, after working with an ethics consultant, not to take a public lobbying stance on the issue of legalization. "But people in the community look to us as experts in this area, and we wanted to support our staff with our policy," Brenneis says.
Other issues that should be addressed include whether staff or volunteers can be present at an assisted suicide not to assist in the suicide but to provide support to the family. Can the hospice’s medical director participate in certifying the patient’s competence or order the medication? Will the agency offer a "conscience clause" to staff who are strongly opposed, allowing them to transfer off cases where it is being seriously considered? Must staff or volunteers report back to the team and by extension the physician whenever a patient brings up the issue, even if the patient requests that it be held in confidence?
Hospices also should review their protocols for assessing clinical depression in patients, bearing in mind that treatable depression might contribute to a patient’s desire for assisted suicide. They also are challenged to reconcile agency philosophy and policy with the wide range of personal views likely to be held by staff, in order to promote a standard of care that is the same regardless of individuals’ beliefs.
Phyllis Taylor, RN, BA, ET, nurse educator/ counselor at Hospice of the Delaware Valley in Plymouth Meeting, PA, emphasizes training staff and volunteers in how to respond to the wide range of potential situations that might arise. At the same time, she says, staff must rely on their own professional judgment in dealing with the unique situations they encounter. "Staff will do what they think is right under the circumstances, and hospices have to be ready for that," she says.
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