Role of the Nursing Professional in Euthanasia: A Qualitative Systematic Review

López-Matons N., Terribas i Sala N., Costas-Muñoz E.

Busquets-Surribas M.

Vieira-Galán O.

Crusat-Abelló E., Fernández-Ortega P.

Revisar la evidencia disponible sobre actitudes y conocimientos que tienen las enfermeras en torno a la eutanasia. Se realizó una revisión de la literatura en las bases de datos: PubMed (incluyendo Medline), CINAHL, Scopus, PsycINFO, Web of Science y CUIDEN, con términos inclusivos de actitudes y conocimientos en torno a la eutanasia, de enfermeras tanto a nivel nacional como internacional. Los criterios de inclusión fueron artículos publicados en castellano, inglés, catalán o francés, periodo de búsqueda limitado desde enero de 2012 a septiembre de 2019, estudios que analizaran actitudes y conocimientos de las enfermeras en torno la eutanasia y poder disponer del artículo completo para su análisis. Se encontraron inicialmente 566 artículos, de los cuales ocho cumplieron los criterios de inclusión sobre la pregunta de investigación planteada en la revisión. El número total de enfermeras participantes estudiadas son 3.571. La mayoría de las enfermeras, tanto a nivel internacional como nacional, presentan una actitud positiva hacia la legalización de la eutanasia; no obstante, todos los estudios reportan un déficit de conocimientos de las enfermeras sobre la temática específica de la eutanasia. Los resultados encontrados muestran que las enfermeras describen su actitud como positiva hacia la práctica de la eutanasia. En cuanto a los conocimientos, se puede concluir en la necesidad reportada por las enfermeras de disponer de más formación específica sobre esta temática. Además, esta revisión ofrece una visión global y actual que puede servir como punto de partida necesario para seguir trabajando y avanzando en la formación de enfermería y en investigaciones futuras. To review the available evidence on nurses’ attitudes to and knowledge about euthanasia. A literature review was carried out in the databases: PubMed (including Medline), CINAHL, Scopus, PsycINFO, Web of Science and CUIDEN, with inclusive terms of nurses’ attitudes and knowledge regarding euthanasia both nationally and internationally. The selection criteria were articles in Spanish, English, Catalan or French published from January 2012 to September 2019 and studies that analysed the nurses’ attitudes and knowledge regarding euthanasia and articles that were full available for analysis. Initially a total of 566 articles were found, and finally 8 met the inclusion criteria of the research question in the review. The total number of nurses participating in the studies was 3,571. Most of the nurses, both at international and national level, have a positive attitude towards the legalization of euthanasia; however, all studies report a lack in nurses’ knowledge on the specific theme of euthanasia. The results show that nurses describe their attitude as positive towards the practice of euthanasia. In terms of knowledge, nurses reported the need to have more specific training on this subject is conclusive. In addition, this review provides a global and current vision that can serve as a necessary starting point for further work and progress in nurse training and for future research.

Yazdanparast E., Davoudi M., Ghorbani S.H., Akbarian A., Chenari H.A.

Euthanasia is one of the most controversial issues in medical ethics and one of the ten major ethical challenges in medicine and health sciences. The present study was conducted to evaluate the relationship between moral sensitivity and attitudes toward euthanasia among nursing students at Birjand University of Medical Sciences in 2020. Birjand University of Medical Sciences has four nursing schools. Cluster sampling method was used for selection of samples. After sampling Ferdows nursing school was selected. Nursing students of Ferdows School were 156 person which 144 participated in the study based on inclusion and exclusion criteria. Students completed demographic information questionnaire, moral sensitivity questionnaire and euthanasia attitude questionnaire. Data were entered into SPSS software version 19 using descriptive and inferential statistical methods. Findings of this study showed that among nursing students, the mean score of moral sensitivity was 59.59 ± 11.21 and was moderate. The mean score of attitudes towards euthanasia was 0.981 ± 0.336. In addition, according to the results, correlation test showed that there is a significant direct but weak relationship between moral sensitivity and attitude to euthanasia in students (P < 0.01, R = 0.219). According to the findings of the present study, moral sensitivity as a scientific concept is one of the determining factors in attitudes toward euthanasia, but other factors can also affect nurses' attitudes toward euthanasia, which should be investigated and determined in future research.

Van Humbeeck L., Piers R., De Bock R., Van Den Noortgate N.

Wilson M., Wilson M., Edwards S., Cusack L., Wiechula R.

Background: Legal assisted dying is a rare event, but as legalisation expands, requests for it will likely increase, and the nurse most often receives the informal, initial request. Objectives: To assess the effects of attitude in interaction with normative and control beliefs on an intention to respond to a request for legal assisted dying. Ethical considerations: The study had the lead author’s institutional ethics approval, and participants were informed that participation was both anonymous and voluntary. Methodology: This was a cross-sectional correlational study of 377 Australian registered nurses who completed an online survey. Generalised linear modelling assessed the effects of independent variables against intended responses to requests for legal assisted dying. Results: Compared to nurses who did not support legal assisted dying, nurses who did had stronger beliefs in patient rights, perceived social expectations to refer the request and stronger control in that intention. Nurses who did not support legal assisted dying had stronger beliefs in ethics of duty to the patient and often held dual intentions to discuss the request with the patient but also held an intention to deflect the request to consideration of alternatives. Discussion: This study advances the international literature by developing quantified models explaining the complexity of nurses’ experiences with requests for an assisted death. Attitude was operationalised in interaction with other beliefs and was identified as the strongest influence on intentions, but significantly moderated by ethical norms. Conclusion: The complex of determinants of those intentions to respond to requests for an assisted death suggests they are not isolated from each other. Nurses might have distinct intentions, but they can also hold multiple intentions even when they prioritise one. These findings present opportunities to prepare nurses in a way that enhances moral resilience in the face of complex moral encounters.

Cayetano-Penman J., Malik G., Whittall D.

Aim Nurses have a critical role in providing holistic care for people with life-limiting conditions. However, they experience internal moral conflict and powerlessness when patients request them to assist in the dying process. A scoping review was undertaken to determine what is known about nurses’ perceptions and attitudes of euthanasia. Review Methods: Several databases were searched that yielded both qualitative and quantitative primary peer-reviewed research studies that focused on nurses, their perceptions and attitudes about euthanasia. Descriptive and explorative analyses of the data set from the research studies were undertaken. Results: A total of 23 studies were included in the review. Opinions about euthanasia were mixed. Two key concepts emerged from the review: some nurses were positive and/or supportive of euthanasia, while some were negative and/or unsupportive of euthanasia. The main factors associated with being positive and/or supportive were because of (a) extreme uncontrollable pain, unbearable suffering, or other distressing experiences of the patient, (b) legality of euthanasia, and (c) right of the patient to die. The factors that determined nurses’ negative and/or unsupportive attitude included (a) religion, (b) moral/ethical dilemmas, (c) role of gender of the health professional, and, (d) poor palliative care. Conclusions: The matter of euthanasia has challenged nurses considerably in their aim to deliver holistic care. There were several crucial factors influencing nurses’ perceptions and attitudes, and these were affected by their personal, professional and transpersonal perspectives. The potential implications to nurses relate to education, practice, and research. Nurses need to be informed of existing legislation and provided in-depth education and professional guidelines to help direct action. Further research is needed to explore the impact on nurses’ emotional well-being, clarify their role/s and determine the support they might require when involved with euthanasia.

Pesut B., Thorne S., Schiller C.J., Greig M., Roussel J.

Medical Assistance in Dying (MAiD) was legalized in Canada in June, 2016. The Canadian government’s decision to legislate assisted dying, an approach that requires a high degree of obligation, precision, and delegation, has resulted in unique challenges for health care and for nursing practice. The purpose of this study was to better understand the implications of a legislated approach to assisted death for nurses’ experiences and nursing practice. The study used a qualitative approach guided by Interpretive Description. Semi-structured interviews were conducted with 59 registered nurses and nurse practitioners. Interviews were audio-recorded, transcribed, and managed using qualitative analysis software. Analysis followed a procedure of data immersion, open coding, constant comparative analysis, and the construction of a thematic and interpretive account. Nurses in this study described great variability in how MAiD had been enacted in their work context and the practice supports available to guide their practice. The development of systems to support MAiD, or lack thereof, was largely driven by persons in influential leadership positions. Workplaces that supported a range of nurses’ moral responses to MAiD were most effective in supporting nurses’ well-being during this impactful change in practice. Participants cited the importance of teamwork in providing high quality MAiD-related care; although, many worked without the benefit of a team. Nursing work related to MAiD was highly complex, largely because of the need for patient-centered care in systems that were not always organized to support such care. In the absence of adequate practice supports, some nurses were choosing to limit their involvement in MAiD. Data obtained in this study suggested that some workplace contexts still lack the necessary supports for nurses to confidently meet the precision required of a legislated approach to MAiD. Without accessible palliative care, sufficient providers, a supportive team, practice supports, and a context that allowed nurses to have a range of responses to MAiD, nurses felt they were legally and morally at risk. Nurses seeking to provide the compassionate care consistent with such a momentous moment in patients’ lives, without suitable supports, find themselves caught between the proverbial rock and hard place.

Green G., Reicher S., Herman M., Raspaolo A., Spero T., Blau A.

Caregivers such as nurses and nursing students have different religiosity backgrounds and have important roles as to terminally ill patients and euthanasia; however, they have different levels of knowledge and experience. Accordingly, the study identify differences between caregivers' religiosity level and euthanasia attitudes, examine differences between caregivers regarding attitude to euthanasia and identify differences between nurses by incidence of terminal patient caring and their relationship to euthanasia. Caregivers (210) volunteered fulfill survey. Main result suggests differences mostly between secular and traditional groups as to euthanasia. Accordingly, our suggestion is that the caregivers should improve communication via simulation of discussing euthanasia.

Yildirim J.G.

The descriptive study was conducted to investigate the knowledge, opinions, behaviors of senior nursing students regarding euthanasia and factors in Islam influencing these. Almost all students (97.7%) knew about euthanasia. Their knowledge, opinions and behaviors were affected by their beliefs about death, religious beliefs and the idea of being subject to euthanasia themselves. Religion influenced whether they wanted euthanasia to be legalized or would carry it out secretly. Students who would be willing for their relatives to undergo euthanasia would not want to participate in this. Knowledge about the concept of euthanasia should be increased and the subject further investigated in many dimensions.

Verhofstadt M., Van Assche K., Sterckx S., Audenaert K., Chambaere K.

Since Belgium legalised euthanasia, the number of performed euthanasia cases for psychological suffering in psychiatric patients has significantly increased, as well as the number of media reports on controversial cases. This has prompted several healthcare organisations and committees to develop policies on the management of these requests.Five recent initiatives that offer guidance on euthanasia requests by psychiatric patients in Flanders were analysed: the protocol of Ghent University Hospital and advisory texts of the Flemish Federation of Psychiatry, the Brothers of Charity, the Belgian Advisory Committee on Bioethics, and Zorgnet-Icuro. These were examined via critical point-by-point reflection, focusing on all legal due care criteria in order to identify: 1) proposed measures to operationalise the evaluation of the legal criteria; 2) suggestions of additional safeguards going beyond these criteria; and 3) remaining fields of tension.The initiatives are well in keeping with the legal requirements but are often more stringent. Additional safeguards that are formulated include the need for at least two positive advices from at least two psychiatrists; an a priori evaluation system; and a two-track approach, focusing simultaneously on the assessment of the patient's euthanasia request and on that person's continuing treatment. Although the initiatives are similar in intent, some differences in approach were found, reflecting different ethical stances towards euthanasia and an emphasis on practical clinical assessment versus broad ethical reflection.All initiatives offer useful guidance for the management of euthanasia requests by psychiatric patients. By providing information on, and proper operationalisations of, the legal due care criteria, these initiatives are important instruments to prevent potential abuses. Apart from the additional safeguards suggested, the importance of a decision-making policy that includes many actors (e.g. the patient's relatives and other care providers) and of good aftercare for the bereaved are rightly stressed. Shortcomings of the initiatives relate to the aftercare of patients whose euthanasia request is rejected, and to uncertainty regarding the way in which attending physicians should manage negative or conflicting advices, or patients' suicide threats in case of refusal. Given the scarcity of data on how thoroughly and uniformly requests are handled in practice, it is unclear to what extent the recommendations made in these guidelines are currently being implemented.

Wilson M., Oliver P., Malpas P.

This study investigated New Zealand nurses’ views on legalising assisted dying across a range of clinical conditions, nurses’ willingness to engage in legal assisted dying, potential deterrents and enablers to such engagement, and nurses’ perceptions of the proper role of their professional bodies in relation to legalising assisted dying. A Bill for legalising assisted dying is currently before the New Zealand parliament. Of the 16 jurisdictions where assisted dying has been specifically legislated, only the Canadian federal statute provides nurses with explicit legal protection for their performance of assisted dying-related tasks. An absence of policy development and planning for safe nursing practice prior to legalisation of assisted dying results in a gap in professional support and guidance. Exploratory cross-sectional survey. A self-selected sample of 475 New Zealand nurses responded to an anonymous online survey disseminated through the newsletters and websites of relevant medical and nursing professional bodies. A sub-sample of nurses who expressed support for or ambivalence about legalisation (n = 356): rated their level of support for legalising assisted dying in New Zealand across a range of medical conditions, and their willingness to participate in a range of assisted dying tasks; identified barriers and facilitators to potential participation; and assessed the responsibility of the professional bodies to provide practice supports. Mixed-method approach using descriptive analysis of quantitative data; qualitative data were analysed thematically. Nurses supported legalisation at a rate (67%) significantly greater than that of doctors (37%) and for a diverse range of medical conditions. Most supporting nurses were willing to engage in the full range of relevant assisted dying roles. They identified several practical and ethical supports as essential to safe engagement, in particular practice guidelines, specific training, legal protections, clinical supervision and mentoring, and independent review of assisted dying service provision. They saw the facilitation of these supports as primarily the responsibility of their professional bodies. Nursing bodies should proactively facilitate workforce awareness and development of assisted dying policy and practice supports in anticipation of legalisation. This can be done through information campaigns and by adapting assisted dying policy, practice materials and systems already developed internationally. Nursing bodies need to engage in formulating legislation to ensure inclusion of explicit protections for participating nurses and to delegate relevant responsibilities to regulatory bodies.

Demedts D., Roelands M., Libbrecht J., Bilsen J.

WHAT IS KNOWN ABOUT THE SUBJECT?: Euthanasia because of unbearable mental suffering (UMS euthanasia) has been legal in Belgium since 2002 under strict conditions of careful practice. UMS euthanasia occurs fairly rarely in Belgium, but the frequency has increased substantially over the past few years. Although most mental health nurses play an important role and are supportive of euthanasia in general, their role, attitude and knowledge when it comes to UMS euthanasia were unknown until now. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Most mental health nurses in Belgium appear to be supportive towards UMS euthanasia and where UMS euthanasia is carried out, mental health nurses are often involved in the preceding decision-making process. Mental health nurses critically reflect on the interpretation and application of the legal euthanasia criteria as experienced in their daily work with their patients, and identify several problems. After a rather quiet period in Belgium, the public ethical debate regarding UMS euthanasia has recently been reopened and intensified. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Sufficient attention must be paid to how mental health nurses can be involved in the process of UMS euthanasia. This applies at several levels: legal, healthcare policy, bedside care and education. Specific attention must be paid within the UMS euthanasia process to ensure adequate cooperation between physicians, nurses and patients. There is a need for proper training in: knowledge of psychiatric pathologies and remaining treatment options; communication skills; the legal framework and all its difficulties; transdisciplinary and multicultural approaches; ethical reflection and how nurses handle their own emotions.Introduction Euthanasia because of unbearable mental suffering (UMS euthanasia) has been legal in Belgium since 2002, under certain circumstances that govern careful practice. Despite the legal framework, there are specific difficulties and concerns regarding UMS euthanasia. Mental health nurses are often involved in the process, but little is known about their attitudes towards UMS euthanasia, their role and their knowledge. Aim To determine the attitudes, role and knowledge of mental health nurses regarding UMS euthanasia. Methods A cross-sectional survey was performed at a convenience sample of four psychiatric hospitals in Belgium (n = 133) as a pilot study. Self-administered questionnaires were provided to mental health nurses. Results Half the nurses in our sample had been involved at least once in the process of UMS euthanasia. A large majority of mental health nurses were supportive of UMS euthanasia. Nurses show differences in attitudes related to the different psychiatric pathologies of the patients, and in whether or not minors are involved. In some cases, they believed that the mental suffering of psychiatric patients can be unbearable and irreversible and that psychiatric patients can be competent to voluntarily request UMS euthanasia. Nurses stated that they have an important role in the UMS euthanasia process, but also demanded more knowledge and clear guidelines to implement the procedure. Discussion Nurses have a key role regarding UMS euthanasia but face several challenges: the recent process, resistance to a multidisciplinary approach by psychiatrists and an unclear role defined by the legal framework. Nurses do not appear to have a common voice on the topic and the development of clear guidelines appears to be essential. Social recovery can offer a way out of an UMS euthanasia request, but it will not always offer a solution. Implications for Practice Sufficient attention must be paid to how mental health nurses can be involved in the process of UMS euthanasia at various levels: bedside practice, healthcare management, education and policy. A form of systematic cooperation between nurses, physicians and patients can contribute to the utmost careful decision-making process needed in these cases. There is a need for proper training in: knowledge of psychiatric pathologies and remaining treatment options; communication skills; the legal framework and all its difficulties; transdisciplinary and multicultural approaches; ethical reflection and how nurses handle their own emotions.

Terkamo-Moisio A., Gastmans C., Ryynänen O., Pietilä A.

Background: Nurses’ voices remain unheard in most debates about euthanasia, although their crucial role in the euthanasia process is widely acknowledged. Moreover, in Canadian euthanasia law, nurses have a more active role, which further highlights the need for knowledge about nurses’ attitudes towards their role in the euthanasia process. Research questions: What are Finnish nurses’ attitudes towards their potential role in the euthanasia process? Which characteristics are associated with those attitudes? Research design: Cross-sectional web-based survey. Participants and research context: 1003 nurses, recruited via social media and the members’ bulletin of the Finnish Nurses Association. Ethical considerations: Ethical approval was obtained from the Committee on Research Ethics of the university to which the first author was affiliated. Findings: The great majority (85.2%) of nurses felt that their perspective should be considered in decision-making related to euthanasia. Furthermore, most of the participants (74.7%) reported willingness to participate in the euthanasia process if it were legal, and 88.6% agreed that a nurse should be present when euthanasia is performed if the patient wishes so. Furthermore, over half agreed that some of the preparatory tasks were part of their job description. However, a minority (32.9%) agreed with a possible obligation to participate based on their profession. Nurses’ age, religiosity and educational level influenced their attitudes in the current results. Discussion: Despite the strong agreement on decision-making concerning euthanasia and participation in the euthanasia process, obligation to participate based on the profession was rejected by most participants. Nurses regarded themselves as consultants in the decision-making process, which may indicate their unwillingness to share the responsibility for the decision itself. Conclusion: Specific safety mechanisms should be considered to protect nurses who refuse to be involved in the euthanasia process due to harm that involuntary participation might cause.