Claire Bentley considers how healthcare professionals should respond when in challenging conversations with patients who feel their life is unendurable and wish to explore assisted suicide.
Background and current position
Individuals such as Diane Pretty, Debbie Purdy and most recently Tony Nicklinson have asked British courts to consider the complex and emotive area of assisted suicide.
Currently the Suicide Act 1961 makes it a criminal offence to encourage or assist a suicide or a suicide attempt in England and Wales. (In the RCNs view this would include providing contact details for organisations that promote or provide support for people wishing to commit suicide). Committing such an offence carries a maximum penalty of up to 14 years in prison. The law draws a clear distinction between actively assisting someone to bring about their own death which is unlawful, and the withdrawal or withholding of life sustaining treatment which can be lawful (perhaps as a result of an advance decision).
In July 2009 the House of Lords decided as a result of the case brought by Debbie Purdy that the Director of Public Prosecutions (DPP) should publish a statement of guidance in relation to assisted suicide. The DPP set out a framework to assist prosecutors to decide which cases should be prosecuted. The framework sets out factors for and against prosecution with some factors given more weight than others. The guidelines do not change the law on assisted suicide and do not offer guarantees to any individual. A prosecution is more likely to be required if:
- The victim was under 18 years of age
- The victim did not have the capacity to reach an informed decision to commit suicide
- The suspect was acting in his or her capacity as a medical doctor, nurse or other health care professional, a professional carer (whether for payment or not), or as a person in authority, such as a prison officer, and the victim was in his or her care.
In January 2012 the Commission on Assisted Dying published a controversial report stating that the current legal status of assisted dying is "incoherent and inadequate". They have called for the law to be changed to allow those who are over 18, have capacity, a terminal illness, have not been coerced and who have less than 12 months to live; the option of choosing assisted suicide. The proposals place much of the responsibility on doctors. In response the BMA said "Whilst there is a spectrum of views on assisted dying within the medical profession, the BMA believes that the majority of doctors do not want to legalise assisted dying”. In addition, the Ministry of Justice have said that "The Government believes that any change to the law in this emotive and contentious area is an issue of individual conscience and a matter for Parliament to decide rather than Government policy."
Tony Nicklinson who has locked in syndrome has asked the High Court to declare that it is lawful for a doctor to terminate his life, with his consent and with him making the decision with full mental capacity. This case goes beyond assisted suicide as Tony Nicklinson can only be killed and can not help to kill himself because of his condition.
In Scotland in January 2010 the End of Life Assistance (Scotland) Bill was introduced in the Scottish Parliament in an attempt to set out new legislation on assisted suicide for Scotland. This was defeated in December 2010. In January 2012, Margot Macdonald has launched a new consultation on legalising assisted suicide.
The Council of Europe has recently ruled that euthanasia and assisted suicide should be banned in every country in the Continent. The non-binding resolution is entitled "Protecting human rights and dignity by taking into account previously expressed wishes of patients", and the amendment states "euthanasia in the sense of the intentional killing by act or omission of a dependant human being for his or her alleged benefit must always be prohibited." This resolution represents a serious setback for assisted suicide campaigners in the UK.
In March, MPs in Westminster will debate the issue of whether the DPP guidance on assisted suicide should be put on a statutory basis.
Royal College of Nursing Guidance
When conversations about assisted suicide take place, some healthcare professionals feel ill-prepared, concerned about their legal position or worried about possible professional sanctions. In October 2011 the RCN published guidance for nurses and healthcare assistants on how to respond to requests from patients in relation to assisted suicide. The helpful guidance merits being read in detail (see link below) as it sets out points to consider in certain scenarios and frequently asked questions.
Some of the key points for healthcare professionals are:
- There is a distinction between end of life decisions that are part of palliative care and acting to end life.
- If you feel you lack the skills to manage the conversation, acknowledge what the patient has said and suggest the patient speaks to a more experienced colleague.
- Bear in mind that a number of conversations may be necessary.
- Put aside your own personal beliefs on the issue of assisted suicide.
- Make it clear that you cannot do anything or provide information about shortening life but try to identify any helpful interventions that are available such as advance decisions.
- Show empathy and avoid sympathy. Listen very carefully and acknowledge what the patient has said whilst taking time to explore the background. This may uncover previously unmet needs.
- Consider cultural and religious implications of the request.
- Let the patient know that you will need to share their request with other team members in order to obtain proper support for the patient.
If a family member or carer asks for assistance in hastening someone's death consider in addition to the above:
- Whether the family member would like to be more informed or involved in the advanced care planning process?
- Whether the relative has concerns about the patient’s capacity?
- Whether the patient is at risk, and if necessary raise a safeguarding alert according to your local policy.
- Sharing information with the family member/carer about the end of life process.
After any conversation
- If an advance decision exists, discuss its applicability and relevance in a multidisciplinary meeting.
- A copy of the most up – to – date advance care plan should be made available to everyone involved in caring for the patient in any care setting, especially out of hours care providers.
- Make a record of any discussion to help inform multi disciplinary teams.
- Advise other members of the care team.
For many people life can retain meaning, even when death is near. The RCN believes that when patients are offered skilled palliative and end of life care, requests for assisted suicide may become less frequent.
This is a complex area legally and ethically and at Bevan Brittan we can provide advice and training to support you and your staff.
Policy for Prosecutors in Respect of Cases of Encouraging or Assisting Suicide – DPP (February 2010)
Treatment and care towards the end of life: good practice in decision making. (July 2010) GMC guidance which sets out a framework for good practice when providing treatment and care for patients who are reaching the end of their lives.
RCN guidance - When someone asks your assistance to die: RCN guidance on responding to a request to hasten death. (October 2011)
The commission on assisted suicide – DEMOS January 2012
Council of Europe. Parliamentary Assembly. Protecting human rights and dignity by taking into account previously expressed wishes of patients.