In jurisdictions where medical aid in dying (MAID) is legal, many hospices require staff to leave the room when a patient ingests aid-in-dying medication. These controversial policies were the focus of a recent ethics consultation conducted by the American Clinicians Academy on Medical Aid in Dying, a group of ethicists that fields requests pertaining to ethical questions involving MAID.1,2
The case involved a patient who ingested aid-in-dying medications at home. The nurse initially left the room, as required by hospice policy. However, the patient started choking on the medication, and the family asked the nurse to come back to the room to assist. The nurse did so and documented the events in the medical record.
Shortly afterward, the nurse was fired because of the policy violation. The nurse contacted ethicists for an opinion on whether the hospice policy was ethical. The ethicists explored these questions: Was it ethical for the hospice to require nursing staff to leave the room? Did the policy compromise the nurse’s ethical obligation to the patient and family?
“These policies are not uncommon. Many hospices have taken that position,” says Constance Holden, RN, MSN, one of the ethicists who reviewed the case as a member of the American Clinicians Academy on Medical Aid in Dying.
The ethicists consulted with other hospices with similar policies in place and asked about the rationale for the policies. The hospices pointed to a 1997 statute that restricts the use of federal funding used in the delivery of care to people who are choosing “assisted suicide, euthanasia, or mercy killing.”3
“The law in all of the 11 jurisdictions where MAID is allowed clearly stipulates that MAID is not suicide or euthanasia, and requires that the patient self-administer the medications,” Holden notes.
Nothing in the current state aid-in-dying laws prohibits nurses from remaining present when medications are ingested. Even so, the hospices believed developing policies requiring staff to leave the room were protective from a legal and regulatory standpoint.
“The hospices thought that if their staff were not present when the patient ingested the medication, it put them at arm’s length, and then there could be no question about the nurse participating in the ingestion,” Holden explains.
Ultimately, the ethicists determined the hospice policies requiring staff to leave the room at the time of ingestion were not ethically justifiable.
“We recommended that hospices drop these policies, to allow nurses to support their patients clinically and emotionally, and not abandon patients at a critical moment because of outdated hospice policies,” says Thaddeus Mason Pope, JD, PhD, HEC-C, another of the ethicists who participated in the consult and a professor of law at Mitchell Hamline School of Law in Saint Paul, MN.
Part of the nurse’s ethical and professional obligations is to ensure patients are taking medication safely. This could include nurses making sure the patient ingests the medication, or ensuring the patient is sitting up. “Those are the things that we are taught to assess as a nurse,” Holden says. “The issue of abandonment of a patient seemed to us to be an ethical principle and a value of professional practice that was being violated.”
The ethicists also concluded the hospice policies requiring staff to leave the room reinforced stigma regarding MAID. “We talked about how it’s really contrary to the hospices’ mission, which is to diminish fear and discomfort, and to convey to the patient that the way they choose to die is acceptable,” Holden says.
Supporting someone who is using the legal act of MAID is “not only legal, but ethical,” Holden adds. The policies requiring staff to leave the room, in the view of the ethicists, seemed to suggest otherwise. Thus, the ethicists recommended hospices change policies to omit any references to staff needing to leave the room at the time of ingestion.
“It’s non-binding; nobody needs to follow the advice we gave,” Holden admits. “However, we are aware of a few hospices that are changing their policies in light of our recommendation.”
Alternatively, the ethicists recommended hospices should at least be open and transparent with patients about the degree to which the hospice will participate with MAID. Any restrictions on staff participation should be made clear. “This way, patients can make an informed choice when selecting a hospice,” Pope says.
REFERENCES
1. Abbott J, Kerwin J, Holden C, et al. Hospice nurse ethics and institutional policies toward medical aid in dying. Am J Nurs 2023;123:37-43.
2. American Clinicians Academy on Medical Aid in Dying. Navigating conflict between professional nursing commitments to patients and institutional “leave the room” policies. Jan. 4, 2022.
3. Assisted Suicide Funding Restriction Act, 42 U.S. Code § 14402. Restriction on use of federal funds under health care programs. Effective April 30, 1997.
Ethicists recommend hospices consider revising policies so nurses can support their patients clinically and emotionally at a critical moment.
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