Ethics Nursing Assisted Suicide

Cynthia Cortez is a fifty-five-year-old teacher living in Tampa, FL. She is married to her college sweetheart, Andrew, and is a mother of two young women, Marissa and Jennifer. She recently went to her primary care physician after experiencing difficulty swallowing and changes in her speech. After undergoing an electromyography, nerve conduction study, an MRI, and several blood tests, her doctor diagnosed her with amyotrophic lateral sclerosis, commonly known as Lou Gehrig’s disease. Cynthia listened as her doctor explained the prognosis. She began to think of her daughters as the physician told her she would gradually lose control of her voluntary muscles that control movement, speech, and eating. She thought about not being able to walk her daughter down the aisle next summer, as the physician told her eventually she would lose the ability to control her involuntary muscles that control her breathing. She then began to think about Andrew and the burden she would become on her family. The physician ended the conversation stating that most individuals diagnosed with this degenerative disorder die of respiratory failure within three to five years from the time the first symptoms began. She held back tears as she asked what her options were. The physician explained that as the disease progressed she would not be able to walk, stand, or get out of bed on her own and would lose the use of her arms and hands. She also would have to be careful when chewing food because as the disease progresses choking is common. Her physician told her now would be the time to write an advanced directive or a living will.

Over the following ten months walking became more difficult and Cynthia began to use a walker. After a year, she needed a wheelchair to get around. Two years after her diagnosis Cynthia’s swallowing became severely impaired resulting in the development of aspiration pneumonia leaving her hospitalized for a week. Due to her mother’s medical needs her daughter Marissa moved home and became Cynthia’s fulltime caregiver. Following this hospitalization, she chose to have a tracheostomy placed to delay respiratory failure and a PEG tube for nutrition. Four and a half years after her initial diagnosis she has now become bedridden. Her family has watched her deteriorate from a vibrant, active, independent woman to a woman who could no longer speak, no longer breath independently, no longer walk, and no longer care for herself.

Cynthia needs to be repositioned every two hours to avoid the development of pressure sores. Her family suffers as they watch her deteriorate knowing she would not want to live in this physical state, but all they are able to do is follow Cynthia’s advance directive. Cynthia lives in Florida, a state in which physician assisted suicide is not legal, her only option was to write an advance directive stating she wants the removal of her tracheostomy tube and her PEG tube once her quality of life deteriorates. Because physician assisted suicide is illegal, Cynthia has been forced to choose terminal dehydration to hasten her death. She feels this is her only option. Cynthia lives for another two and a half weeks before passing.

According to Schwarz “often just knowing a way out exists if the dying process is unbearable can provide relief from desperation that could lead to a more violent solution.” One of the biggest issues facing those diagnosed with a terminal condition is the lack of control. The patient knows they have about six months to live and in cases like Cynthia they know that their body will turn on them and their dying process will not be peaceful. Many individuals with ALS die due to an excess of carbon in their bodies resulting in respiratory failure and death. These patients need to feel as though they are in control during a time in which they have very little control and they fear the progression of their condition will be worse than death. Since Oregon’s Death with Dignity Act was passed in 1997 “more than 1,100 in the state have filled life-ending prescriptions under Oregon’s Death with Dignity Act. However, only about 750 have actually used the drugs to die (Bever, 2014).” A study in Canada found that individuals 65 and older “with three physical illnesses had approximately a threefold increase in estimated relative risk for suicide compared with subjects who had no diagnosis, whereas older adults who had seven or more illnesses had approximately nine times greater risk for suicide” (Conwell, Orden, & Caine, 2011).

A legal alternative to physician assisted suicide is to voluntarily stop eating or drinking (VSED). VSED is different from the natural decrease in desire to eat or drink that is frequently seen in terminally ill patients. VSED is when a person voluntarily refused to eat or drink anything once the patient choses this option many die within 1-3 weeks from terminal dehydration. This option provides the patient a level of autonomy that must be respected by medical professionals. Although this is a legal way to hasten a person’s death, many patients who chose this option experience “apathy, lethargy, coma, confusion, increased risk for pulmonary embolism and deep vein thrombosis, headaches, nausea and vomiting, muscle cramps, increase risk of urinary tract infection, dysuria, dry mouth, and thirst.” If a patient chooses VSED the nurse then supports their autonomy and manage these symptoms (Lachman, 2015).

Another alternative to PAS is palliative sedation, but many physicians will not authorize this alternative. Palliative sedation is used for patients experiencing severe pain or with symptoms that are not able to be managed without high doses of medications that cause them to become unconscious. For these patients, all nutrition and hydration is terminated and they must be monitored around the clock to ensure adequate sedation.

In June 1990, the Patient Self Determination Act was passed, which allows patients to make medical decisions regarding their care including end of life care and the right to refuse life sustaining treatments. In March 2009, Washington passed their Death with Dignity Act. As of 2017, physician assisted suicide is currently legal in California, Colorado, District of Colombia, Oregon, Vermont, and Washington. On June 9, 2016, California’s AB-15 End of Life Option Act was passed. On November 8, 2016, Colorado passed Proposition 106, the End of Life Options Act. In May 2013, Vermont’s Act 39, Vermont Patient Choice and Control at the End of Life Act was enacted. February 20, 2017, Washington, D.C. enacted the Death with Dignity Act. In December 2009, Montana passed their Death with Dignity Act. Oregon’s Death with Dignity Act was passed in 1997.

Under the Death with Dignity Act the patient must be at least 18 years old, a resident of Oregon, diagnosed with a terminal illness and