Published April 2017 Part of hospital test scenarios, escalation to ethics committee Patients with a terminal illness who communicate their wish to die to a nurse shall receive appropriate care that is in line with institutional procedures, local laws, and their personal preferences. A nurse should be able to rely on the support of the institution he or she works for in terms of training, clear line of responsibility for such decisions, and unambiguously communicated expectations defined in organizational procedures. Assisted suicide is legal in Switzerland and several other European countries, in several states in the U.S., and in Canada. The mental capacity of the patient has to be considered in addition to locally applicable laws. Medical Power of Attorney is helpful if the patient previously described his or her wishes regarding end-of-life decisions and became incapacitated in the meantime. Financial toxicity, in addition to dubious effectiveness, contributes to the reluctance of some patients to undergo aggressive and invasive therapies. German physician Albert Moll in his book Medical Ethics (1902), argues that aggressive care in incurably ill patients is unethical. Healthcare staff, including nurses, can conscientiously object to assisting with suicide.

1. Ethical Dilemmas in Gerontology
Published April 2017
Part of hospital test scenarios, escalation to ethics committee
Patients with a terminal illness who communicate their wish to die to a nurse shall receive
appropriate care that is in line with institutional procedures, local laws, and their personal
preferences. A nurse should be able to rely on the support of the institution he or she works for in
terms of training, clear line of responsibility for such decisions, and unambiguously
communicated expectations defined in organizational procedures. Assisted suicide is legal in
Switzerland and several other European countries, in several states in the U.S., and in Canada.
The mental capacity of the patient has to be considered in addition to locally applicable laws.
Medical Power of Attorney is helpful if the patient previously described his or her wishes
regarding end-of-life decisions and became incapacitated in the meantime. Financial toxicity, in
addition to dubious effectiveness, contributes to the reluctance of some patients to undergo
aggressive and invasive therapies. German physician Albert Moll in his book Medical Ethics
(1902), argues that aggressive care in incurably ill patients is unethical. Healthcare staff,
including nurses, can conscientiously object to assisting with suicide.
In geriatric care, nurses and other healthcare workers, including support staff, witness the decline
of terminally ill patients regularly. Patients who are gradually approaching the end of their lives
express a wide variety of attitudes, wishes, and preferences regarding their care. Considerable
differences exist in the level and quality of support from family and friends, overall fitness and
resilience, personal values and philosophical beliefs, and religious and spiritual affiliations.
Every geriatric nurse can expect to face patients whose ability and willingness to continue their
journey has ended. The circumstances and motivations may vary, depending on personal and
cultural background and life experiences as well as a set of beliefs and attitudes of family
members the patient would have to depend on. However, the desire to leave peacefully is innate
to all humans, regardless of accent, complexion, or cuisine. Confining thoughts of suicide in a
nurse is a logical step for a patient. Nurses are usually the closest and most familiar people
geriatric patients have at this point in their lives. For nurses, however, such knowledge can
represent significant distress due to professional obligations, personal beliefs, and religious
affiliation.
In an institution dedicated to geriatric care, it is reasonable to expect that a nurse would not have
to handle such requests alone. Short of disclosing the identity of the patient in his or her care, a
nurse can request assistance from the institution’s dedicated functions, typically through her
supervisor or manager. Procedures for how to handle decision-making in end-of-life care and
conditions necessary for its cessation, as well as relevant disclosures, have to be in place to
protect the institution from liability due to malpractice, medical error, or negligence. Appropriate
training on existing procedures provided to staff shall define roles and responsibilities as
applicable in specific situations, and prevent improvisation and human error.
Where end-of-life decisions are concerned, the considerations include the mental competency of
the individual to make decisions regarding his or her care previously expressed wishes recorded
in Medical Power of Attorney and locally applicable laws in regards to assisted suicide.

2. According to Euthanasia Research & Guidance Organization (ERGO), an organization dedicated
to providing resources and educational materials on assisted suicide and euthanasia, only
Canada, Colombia, six U.S. states, and five European countries currently allow some form of
assisted suicide. The site is instrumental in clarifying some of the terminologies and explaining
the distinction between assisted suicide and physician-assisted suicide, voluntary and non-
voluntary euthanasia, and terminal sedation. According to the site, terminal sedation means the
use of medications to induce deep sleep, during which the patient dies of the underlying illness,
dehydration, or starvation. Terminal sedation is widely practiced and is generally accepted as
ethical and lawful (“Assisted Suicide”, n.d.).
Switzerland is often cited as a country with the most liberal euthanasia laws in the world.
According to Article 115 of the Penal Code of Switzerland, “Whoever, from selfish motives,
induces another to commit suicide or assist him therein shall be punished, if the suicide was
successful or attempted, by confinement in a penitentiary for not more than five years or
by imprisonment.” Organization Patient Rights Council argues that assisted suicide is not legal,
only unpunishable unless a selfish motive is proven. (“Patients Rights Council”, n.d.).
The situation in Switzerland is explained in detail by Andorno (2013). While active euthanasia
(killing on request) is illegal, the administration of medication to relieve the severe pain of a
terminal patient is accepted as morally and legally justified. The law does not provide for
punishment for the withdrawal or withholding of life-sustaining treatments. The peculiarity of
Swiss laws is in the fact that no terminal medical condition is required and in the limited role of
physicians. Unlike in the Netherlands and Belgium, in Switzerland, the physician can only
prescribe the lethal drug and assess the patient’s mental capacity (Andorno, 2013).
Schwarzenegger and Summers (2005) explain in detail the legal difference between Intentional
killing (Article 111), Murder (Article 112), Manslaughter (Article 113), Killing on request
(Article 114), Inciting and assisting someone to commit suicide (Article 115) and Negligent
killing (Article 117). Legal problems related to assisted suicide include a question of whether or
not a person has the legal capacity to request such assistance. It matters whether it was the victim
or the person who assists who performed the act of self-termination and details and
circumstances of prescription of deadly barbiturates to eliminate pain. Assistance provided by
Swiss organizations such as EXIT or Dignitas is considered lawful because of the absence of
selfish motive, should it be pecuniary profit, publicity, or inheritance (Schwarzenegger &
Summers, 2005).
Similar rules apply in the State of Oregon in the U.S. The Death with Dignity Act, enacted in
October 1997. The act allows the residents of Oregon to self-administer a lethal dose of
medications, prescribed for that purpose by a physician, providing they are terminally ill and that
such deed is voluntary (“Oregon Health Authority”). Experience with this law shows that most
of the 204 patients who received prescriptions under the Death With Dignity Act opted for this
kind of end were 65 years of age or older, and nearly 80% of them had cancer. (Oregon Health
Authority, 2017).
The mental capacity of elderly patients to decide is a problem that nurses face daily. The
cognitive ability of elderly patients can deteriorate gradually over time and is not necessarily

3. consistent during the day. For example, patients who are not legally incapacitated can experience
periods of confusion. On the other hand, patients who are no longer considered competent to
make their own decisions can still have a good understanding of their condition and options at
some time of day. Whether or not a patient has the capacity to request assistance with suicide is a
question that needs to be answered by a physician.
In general, the situation is much easier if there is a Medical Power of Attorney available that
details the patient’s desires and preferences in a way that is clear and unambiguous. The
document may empower a specific individual to decide about the withdrawal or withholding of
life-saving treatment, and allow the administration of pain relief that may lead to the patient’s
death. Medical Power of Attorney also makes it clear who is entrusted with the person’s medical
care and end-of-life decisions. In instances, when family relationships are less than
straightforward, powers granted to a trusted friend are the only way to ensure the protection of
the patient’s rights and interests. Relevant examples include family disputes over inheritance,
unfinished separation or divorce proceedings due to family honor concerns, or unaddressed
paternity issues.
Financial toxicity of many end-of-life treatments and especially innovative cancer therapies
introduces additional ethical dilemmas. Patients’ ability to sustain their end-of-life care often
comes at the expense of other family members. Pressures to maintain the family quality of life
and sustainable finances, including preservation of inheritance that may be passed on to
survivors, may be one motivation to refuse prolonged and aggressive treatments, especially if
these therapies are invasive, expensive, and likely futile.
A survey of more than 10.000 patients conducted by the Center for Disease Cancer care found
that financial problems caused by cancer were the strongest predictor of quality of life (“Cost of
Cancer Care”). Besides, innovative cancer care does not always bring the expected benefits. For
example, gemtuzumab ozogamicin (Mylotarg) was a drug approved in 2000 for the treatment of
Acute Myeloid Leukemia. Mylotarg was eventually withdrawn from the U.S. market in 2010
because of no clinical benefit to patients (“GEN”).
In December 2012, Amgen Inc. pleaded guilty to the federal charge in Brooklyn, N.Y., and paid
$762 Million to resolve criminal liability and False Claims Act allegations arising from the sale
and off-label promotion of its product Aranesp. Aranesp is a drug that stimulates erythropoiesis
that was approved by the U.S. Food and Drug Administration for a specific patient population
with anemia. According to the Department of Justice Amgen also marketed the drug to patients
with anemia caused by cancer chemotherapy, for which it was never approved, exposing these
patients to a higher risk of death (United States Department of Justice, 2012).
Ethical dilemmas relating to medical care for terminally ill patients are not a new problem. In the
late 1800s, German physician Albert Moll collected numerous case studies on medical ethics as
practiced in his days in Germany, and in 1902 published his 650-page book Medical Ethics: The
Doctor’s Duties in All Relations of His Work. Moll fiercely rejected social Darwinism and
eugenic theories so widespread in his time and advocated the contractual relationship between
physicians and their patients. This relationship extended to truth-telling and deception when
dealing with incurably ill patients and their families. Moll rejected heroic treatment efforts that

4. only led to prolonged suffering on terminally ill patients as unethical and would not undertake
them even if the relatives were asking for them. In regards to medical experimentation on dying
patients, Moll condemned such experiments as shameful, brutal, and entirely unacceptable
(Maehle, 2012).
In 2012, the Liverpool Care Pathway made headlines in the United Kingdom. The National
Health Service program was intended to deliver palliative care to dying patients. However, in
practice, the guideline was not implemented with fidelity, and many patients and their families
felt they and their loved ones were denied care and left to die without their knowledge or consent
(“Nursing Times”).
Patient’s wishes aside, if a nurse faces a request from a patient for assistance with suicide, he or
she may decide to opt-out from the patient’s care based on conscience. Healthcare providers and
physicians, but also individual staff such as nurses, administrative staff, emergency medical
technicians, and pharmacists, can object to providing certain medical services. Most often,
healthcare professionals object to providing abortions, reproductive healthcare services,
sterilizations, contraceptives, or blood transfusions. U.S. federal law allows conscientious
objectors may request exemptions from policy and even legal obligations and excuses such
individuals and even institutions from the provision of services they find morally objectionable.
Galston and Rogers (2012) argue that not just doctors, but also nurses and other healthcare
workers, can be excused from performing such duties if they find them morally or religiously
objectionable. (Galston & Rogers, 2012)
If a patient confides plans to commit suicide to a nurse, or even requests assistance to do so,
nurses should be able to turn to supervisors for support rather than tackling the dilemma alone.
Geriatric nurses are likely to encounter such requests at some point in their careers and should
receive specialized training for such situations. Institutions that treat the geriatric patient
population should prepare relevant procedures and train staff to ensure legal compliance and
appropriate and ethical medical practice. In some states, assisted suicide is legal and subject to
strict regulation. Mental competence is a major issue in geriatric patients. It is the responsibility
of a physician to decide whether the patient requesting assistance with suicide is of sound mind
or not. Medical Power of Attorney makes it clear what the patient’s preferences are in regards to
end-of-life care, including withholding and withdrawing life-sustaining treatment and
administering a potentially lethal dose of pain relief. For a nurse, however, such requests can
represent a significant moral dilemma. A conscientious objection can be used to opt-out of
providing care to a patient who wishes to die.
References
Andorno, R. (2013). Nonphysician-Assisted Suicide in Switzerland. Cambridge Quarterly of
Healthcare Ethics,22(03), 246-253. doi:10.1017/s0963180113000054
Dutton, G. (2010). Mylotarg Withdrawal Raises Questions | GEN Genetic Engineering &
Biotechnology News - Biotech from Bench to Business. Retrieved March 23, 2017, from
http://www.genengnews.com/gen-articles/mylotarg-withdrawal-raises-questions/4489

5. Euthanasia Research & Guidance Organization (ERGO). (n.d.). Assisted Suicide - Information
on right-to-die and euthanasia laws and history. Retrieved March 23, 2017,
from http://assistedsuicide.org/
Galston, W. A., & Rogers, M. (2012). Health Care Providers’ Consciences and Patients’ Needs:
The Quest for Balance (pp. 22-35, Rep.). Governance studies at Brookings.
Maehle, A. (2012). ‘God’s Ethicist’: Albert Moll and His Medical Ethics in Theory and
Practice. Medical History,56(02), 217-236. doi:10.1017/mdh.2011.34
NHS Choices. (2012). What is the Liverpool Care Pathway? Retrieved March 23, 2017, from
https://www.nursingtimes.net/clinical-archive/end-of-life-and-palliative-care/what-is-the-
liverpool-care-pathway/5051586.article
Oregon Health Authority. (n.d.). Death with Dignity Act. Retrieved March 23, 2017,
from https://public.health.oregon.gov/ProviderPartnerResources/Evaluationresearch/deathwithdi
gnityact/Pages/index.aspx
Oregon Health Authority, Public Health Division, Center for Health Statistics. (2017). Oregon
Death with Dignity Act Data summary 2016 (p. 3, Rep.). OR: Oregon Health Authority.
Patients Rights Council. (n.d.). Switzerland Current law regarding assisted suicide. Retrieved
March 23, 2017, from http://www.patientsrightscouncil.org/site/switzerland/
Schwarzenegger, C., & Summers, S. J. (2005). Criminal Law and Assisted Suicide in
Switzerland. Hearing with the Select Committee on the Assisted Dying for the Terminally Ill Bill,
House of Lords Zurich, 3 February 2005. In Universität Zürich. Retrieved March 23, 2017,
from http://www.rwi.uzh.ch/lehreforschung/alphabetisch/schwarzenegger/publikationen/assisted-
suicide-Switzerland.pdf
The United States Department of Justice. (2012). Amgen Inc. Pleads Guilty to Federal Charge in
Brooklyn, NY.; Pays $762 Million to Resolve Criminal Liability and False Claims Act
Allegations. Retrieved March 23, 2017, from https://www.justice.gov/opa/pr/amgen-inc-pleads-
guilty-federal-charge-brooklyn-ny-pays-762-million-resolve-criminal
The University of Chicago Cost of Cancer Care. (n.d.). Financial Toxicity Facts. Retrieved
March 23, 2017, from https://costofcancercare.uchicago.edu/page/financial-toxicity-facts