Suffering
ANA’s Social Policy Statement (2010) includes alleviation of suffering as part of the core definition of
nursing, a nursing action fundamental to patient and family- centered care. Requests for medical aid in dying
often originate from fear of unmanaged physical pain, suffering, and loss of control (Hamric, Schwarz,
Cohen, & Mahon, 2018; Sulmasy et al., 2018). States with long-standing statutes that allow medical aid in
dying provide perspectives about the main reasons patients request this option. In Oregon, the most
frequent reasons, which have remained stable since 1997, include loss of autonomy (89.5 percent),
decreasing ability to participate in activities that made life enjoyable (89.5 percent), and loss of dignity (65.4
percent) (State of Oregon Health Authority, 2016).
Fear of intractable pain and suffering associated with dying are very real concerns for people at the end of
life. Some health care professionals might argue that palliative and hospice care are designed to address the
symptoms, pain, and suffering, thus medical aid in dying is not necessary. Indeed, since legalizing medical
aid in dying in Oregon, there has been significant growth in the use of palliative and hospice care resources
(Oregon Health Authority Death with Dignity Annual Reports, 1998–2017). A central feature to ethical
nursing practice in the care of patients requesting medical aid in dying is ensuring exploration of all
alternatives, including high-quality palliative care and aggressive management of pain and suffering. Further
research is needed to better understand the medical aid in dying process and the variables impacting
patient decisions.
Conscience-Based Refusals
Interpretive Statement 1.2 of the Code notes that “respect for patient decisions does not require that the
nurse agree with or support all patient choices” (p. 1), thus the nurse is not required to compromise his or
her integrity in the provision of such care. Such situations may result in the nurse experiencing moral
distress. “When a particular decision or action is morally objectionable to the nurse, whether intrinsically so
or because it may jeopardize a specific patient, family, community, or population, or when it may jeopardize
nursing practice, the nurse is justified in refusing to participate on moral grounds. Conscience-based refusals
to participate exclude personal preference, prejudice, bias, convenience, or arbitrariness” (ANA, 2015a, p.
21). A well-established ethical commitment when declining to provide care on moral grounds is the primacy
of patient care. “Nurses are obliged to provide for patient safety, to avoid patient abandonment, and to
withdraw only when assured that nursing care is available to the patient” (ANA, 2015a, p. 21).
Presence
A patient may request that a nurse be present when the patient ingests the aid in dying medication.
Presence that is consistent with the Code of Ethics for Nurses includes sensitivity to the patient’s
vulnerability, demonstration of care and compassion, and promotion of comfort to sustain trust in an
established nurse-patient relationship (Numminen, Repo, & Leino-Kilpi, 2017). When making the decision on
whether to be present, the nurse should consider personal values and organizational policy, as well as the
professional relationship that exists with the patient and family. If present during medical aid in dying, the
nurse promotes patient dignity as well as provides for symptom relief, comfort, and emotional support to
the patient and family. The nurse must maintain patient confidentiality and privacy in the aid in dying
process. The nurse’s decision to be present should not be negatively evaluated (Ersek, 2004; Johnson &
Weiler, 1990; Orentlicher et al., 2016).
Regional and Organizational Alignment
Nursing: Scope and Standards of Practice (ANA, 2015b) underscores the importance of knowing state
statutes and organizational policies that guide aid in dying practice. “To function effectively, nurses must be
knowledgeable about the Code of Ethics for Nurses with Interpretive Statements; standards of practice for
the profession; relevant federal, state, and local laws and regulations; and the employing organization’s