In July 2009, the Royal College of Nursing announced that, after consultation with their membership, they were withdrawing their historic opposition to assisted suicide, and were moving to a ‘neutral’ position. At the time this was heavily criticised as sending out a message of tacit support for assisted suicide. Furthermore it was based on a response from a tiny sample of the 400,000 strong membership of the RCN, so was also criticised as a major policy change with minimal mandate.
I met with Peter Carter, the General Secretary of the RCN later that summer, and expressed the concerns that many nurses were raising over this move. He sought to reassure me that they main reason was to allow the College to produce more informed guidance for members when faced by requests from patients for assistance with ending their lives. While I still cannot see why a change in position was necessary in order to produce such guidance, I did welcome the decision to give clear professional guidelines. At the time I was told this would be out in the spring of 2010.
Now, in October 2011, the guidance has finally come out! It has proved much harder and more contentious for the RCN to navigate these complex, treacherous legal and ethical waters than it had originally anticipated. Not least because in the intervening period the Director of Public Prosecutions was ordered by the High Court to issue guidance on the grounds for prosecution in cases of assisted suicide – guidance that made it much more explicit that health professionals involved with assisting the death of a patient would face prosecution,
The guidance published today is surprisingly good. It addresses the different legal issues – from the DPP guidelines to the Mental Capacity Act and the provision for advanced directives, to the NMC code of professional practice. More importantly the document offer practical guidance on how to broach end of life issues with patients and their family and carers.
At the core of the policy is the following statement:
Your responsibility is to work within the law to support the patient, and their family or carer, to explore and express their thoughts about the situation. At all times you are required to act ethically and legally, and in a manner that as far as possible empowers and supports people to live well until they die. [emphases mine]
The policy makes it clear that ‘it is important to make it clear that you cannot do anything that would shorten their life, or provide information about or assist in contacting such organisations [which provide information on assisted suicide]’ for either patient, relative or carer. But it looks frankly at the reasons why patients and their families ask for such assistance, and at how to explore sensitively the reasons for the request and the options for palliative care and other support. It also makes it clear that the nurse should not raise the subject her/himself. Above all it stresses that nurses have a duty to work with patients and their families to address their end-of-life care needs, and not to avoid the issue.
This is important, because the subject of death is often skirted round by patient and health professional alike, for a whole host of reasons. Health professionals’ fears of prosecution when the issue of assisted suicide is raised by patients has been used by pro-euthanasia groups to legitimise calls to legalise assisted suicide. However, the guidance makes it clear that it is possible to discuss the issue (if raised by the patient) within existing legislation and codes of professional practice. It offers very practical guidance on how to raise end of life care discussions with patients and their families or carers, which can only be of benefit if approached with care and sensitivity.
The document does explore some difficult issues, and suggests quite strongly that nurses should not discuss their own beliefs about assisted suicide with a patient or relative. Whilst this is generally appropriate, it does limit discussion when a patient or relative asks a specific question about the health professional’s own views. There is a danger that guidance can be too proscriptive. There are times when it is appropriate for a professional to make their own judgement when it is appropriate to respond to such a question.
There is also a detailed exploration of the Mental Capacity Act, the Scottish Adults with Incapacity Act and their implications in the area of Advanced Directives. However, it also makes it clear that no patient can require a health professional to assist with their suicide through an advanced directive.
Overall, this is a useful document that has been worth the wait, not least because it encourages nurse not to shy away from end of life care discussions with patients, and gives practical advice about how to do this sensitively.