New surveys report a range of opinions, need for further education.
Nurses have strong feelings about medical aid in dying (MAID), according to two comprehensive studies of more than 2,300 nurses in the United States from the American Nurses Association (ANA) Center for Ethics and Human Rights and the University of California,San Diego Health.
Both qualitative and quantitative responses explored and described nurses’ values, perceptions, and perspectives on MAID. Nurse respondents reported a need and desire for more guidance on the expectations of their role to provide competent and quality care where MAID is legal.
“These are important, first-of-their-kind studies,” said Liz Stokes, PhD, JD, MA, RN, director of Nursing Programs at ANA and director of the ANA Center for Ethics and Human Rights. “They provide insight into the values and perspectives of ANA members and help to shape best practices for a very complex end-of-life option.”
Quantitative survey shows nurse support
A slight majority of nurses (57%) who participated in a quantitative survey published in the Journal of Hospice and Palliative Nursing said they support MAID in the context of their professional role. Another 49% said they personally support MAID, the highly regulated process in which a patient requests assistance in dying. MAID is not considered euthanasia or suicide, as defined in the article. The patient must be competent at the time of making the decision to enact MAID and physically able to take the medications independently.
In this study, Judy E. Davidson, DNP, RN, FAAN, Genesis Bojorquez, PhD, RN, NE-BC, and five colleagues sent a cross-sectional electronic survey to ANA; 2,390 responded. The authors used 2,043 complete data sets for their analysis.
“To avoid moral distress and moral injury, education coupled with personal introspection is needed for nurses to make informed decisions regarding the decision of whether or not to work in areas where MAID is practiced,” said Davidson, a nurse scientist in the department of nursing at the University of California San Diego in La Jolla and an ANA/California member.
Other key findings include the following:
- 86% of nurses would care for a patient contemplating MAID.
- 67% of nurses would care for a patient in the final act of MAID.
- 38% of nurses believe a patient should be required to self-administer life-ending medications.
- 49% of nurses believe MAID should be allowed by advance directive.
- Nurses were more likely to support the concept of MAID if they felt knowledgeable about it.
- Nurses who described themselves as spiritual were more likely to support MAID than those who described themselves as religious.
A qualitative analysis
In a second study published in Nursing Ethics, Davidson, Stokes, and five colleagues explored nurses’ values and perceptions involving MAID. They sent a cross-sectional electronic survey to ANA members, receiving 3,639 open-ended comments from 1,213 respondents. The authors’ investigation centered around four major values:
- Honoring patient autonomy without judgment
- Honoring with limitations
- Not until…
- Adamantly against
Honoring patient autonomy without judgment
The researchers found that participants held respect for patient choices while maintaining boundaries with their personal beliefs. Some participants reported seeing MAID as a sacred duty. As one observed, “I would be honored to be present as a witness and comfort to a person whose suffering is unbearable to them.”
Participants also perceived MAID to be an obligatory part of nursing care, citing their covenant to the profession to serve all without judgment. They expressed their duty to provide care in terms of nonmaleficence and nonabandonment.
Honoring with limitations
Nurses who participated in the study expressed fear of litigation, being accused of murder, and inadequate legal protection. Respondents stated they would consider participating in MAID if these concerns were addressed. They also expressed concern about the psychological burden MAID would place not only on themselves, but also on a patient’s family and loved ones. Other respondents said that they would consider participating in MAID if certain restrictions were in place, such as allowing only physicians or specialists to administer medications. Others reported that they would consider participating on a case-by-case basis.
The authors found that some nurses didn’t feel ready to decide about MAID, citing a need for more information, along with concerns about policies and processes. They felt that they, as nurses, as well as the patient and patient’s family members, should have a better understanding about the roles, methods, consequences, and complexities involved in MAID.
The authors reported that other respondents were troubled by what they perceived as unfair inclusion and exclusion criteria and expressed concern that MAID policies discriminate against the disabled. As one participant wrote: “Is (MAID) just? What if the patient is physically unable to administer their own medication? Does this limit MAID to only able-bodied patients?”
The study revealed that some respondents believed that MAID would be requested less if people had more awareness of and education about hospice care.
The surveys showed that respondents completely opposed to MAID cited religious beliefs, personal values, and interpretation of nursing ethics.
“I cannot endorse MAID,” wrote one respondent. “I believe God gives life and any suicide or MAID is taking life that only God gives or can take.”
The study found that some nurses equated MAID with suicide or murder or believed it could be a steppingstone to euthanasia. Others saw MAID as anathema to their nursing duty. As one participant wrote: “As nurses we took the Florence Nightingale pledge—that does not involve helping a patient end their own life.”
More knowledge needed
Davidson, Stokes, and colleagues believe that nurses, as the largest healthcare workforce and the most trusted profession, can play a critical role in MAID legislation. However, they pointed out that “knowledge gaps need to be filled before nurses take an active role in policy formation.” The survey findings indicated that nurses frequently are unaware of the laws and nuances of MAID, and some respondents cited their lack of knowledge about the policies and processes as reasons for indecision about participation.
“Education is necessary pre-and post-licensure to ensure that nurses are familiar with the concepts, expectations, and scope of practice related to MAID,” the authors stated. “Competencies are needed for nurses caring for patients receiving MAID.”
The quantitative analysis showed that nurses who had more knowledge about MAID were more likely to endorse the practice.
ANA statements on MAID
ANA’s position on MAID has evolved. In 1994, the association released two position statements: Assisted Suicide and Active Euthanasia. Both affirmed that nurses would not participate in actively taking a human life. A revised, combined position statement, Euthanasia, Assisted Suicide and Aid in Dying, was published in 2013, stating that nurse participation in assisted suicide and euthanasia was in direct violation of the Code of Ethics for Nurses with Interpretive Statements.
In 2019, ANA released The Nurse’s Role When a Patient Requests Medical Aid in Dying, a position statement that aims to address the growing ethical questions and challenges that nurses face when responding to a patient’s request for MAID. Although nurses are still ethically prohibited from administering aid-in-dying medication, ANA advises nurses to remain objective when patients are exploring end-of-life options.
The future of nurses’ involvement in MAID
The studies found that MAID continues to be a serious, yet misunderstood topic among the public, nurses, other healthcare professionals, and policymakers. Nurses must receive and have access to education about their role in MAID, which currently is legal in 10 states plus the District of Columbia with legislation pending in additional states, including Connecticut, Arizona, and Massachusetts. Nurses must be able to confidently respond to a patient’s request for MAID and care for them competently within the legal and defined scope of their practice. Nurses are encouraged to participate in policy discussions as MAID becomes legal in more states. Careful construction of institutional policy and standards will help minimize conflict, moral distress, and psychological harm among nurses.
Elizabeth Moore is a content creator at ANA.
Davidson JE, Bojorquez G, Upvall M, et al. Nurses’ values and perspectives on medical aid in dying: A survey of nurses in theUnited States. Journal Hosp Palliat Nurs. 2022;24(1):5-14. doi:10.1097/NJH.0000000000000820
Davidson JE, Stokes L, DeWolf Bosek MS, et al. Nurses’ values on medical aid in dying: A qualitative analysis. Nurs Ethics. 2022. doi:10.1177/09697330211051029