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Ask the Mental Health Expert Archives 2001-2004

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Choice of Death

Q. I am an RN and a Certified Hospice Nurse (CRNH). I am an advocate of the Right to Die movement and believe that all terminally ill patients have a right to choose how and when they die. In what circumstance must I take steps to avoid the suicide of one of my terminally ill patients?

A. You are asking what is fundamentally a legal question--and I am definitely not a lawyer! As a general statement, it's fair to say that all health care professionals in the U.S. are obligated, under their own professional ethical rules, to prevent a patient's suicide. (In fact, the most common legal action involving psychiatric care is the failure to reasonably protect patients from harming themselves--see Clinical Psychiatry and the Law, by Robert Simon MD). Specifically, the American Nurse's Association has explicitly prohibited nurse-assisted suicide (for an opposing view, see the article by BC White, J Prof Nurs 1999; 15:151-9).

In addition, individual institutions--hospitals, nursing homes, hospices, etc.--probably have their own medico-legal regulations that may differ from place to place, and from state to state. Indeed, in 1997, the U.S. Supreme Court ruled that individuals do not have a constitutional right to physician-assisted suicide, but that individual states can legislate their preference in this matter (see S.F. Pierce, "Allowing and assisting patients to die", J Adv Nurs 1999; 30:616-22). The Pierce article also distinguishes "allowing for a dignified death" from "assisting patients to die"--a distinction that may have critical implications for your work in a hospice setting.

Similarly, whether a patient has left an advance directive, and whether he or she is mentally competent to make health care decisions at the end of life, are important considerations in a nurse's ethical and legal responsibilities. You may want to take a look at the American Nursing Association's position statement on "Care and Comfort in Dying Patients". You may also want to write to DK Kjervik or L. Badzek at the University of North Carolina at Chapel Hill School of Nursing, since they have written on these issues.

Finally, it would be very important to determine what the specific legal requirements are in your state and in your facility, and to obtain legal counsel regarding specific advice. This is certainly a difficult and controversial matter for most of us in the health care profession--but each of us needs to guard against acting from our personal convictions alone.

September 2001

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