- Email: [email protected]
Grave new world: The conspiracy of silence surrounding non-voluntary euthanasia
Journal Pre-proof Grave new world: The conspiracy of silence surrounding nonvoluntary euthanasia
Ya'arit Bokek-Cohen, Mahdi Tarabeih PII:
S0897-1897(19)30659-7
DOI:
https://doi.org/10.1016/j.apnr.2020.151245
Reference:
YAPNR 151245
To appear in:
Applied Nursing Research
Received date:
20 September 2019
Revised date:
30 October 2019
Accepted date:
15 February 2020
Please cite this article as: Y. Bokek-Cohen and M. Tarabeih, Grave new world: The conspiracy of silence surrounding non-voluntary euthanasia, Applied Nursing Research(2018), https://doi.org/10.1016/j.apnr.2020.151245
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2018 Published by Elsevier.
Journal Pre-proof
Grave New World: The conspiracy of silence surrounding non-voluntary euthanasia
of
Dr. Ya'arit Bokek-Cohen (Ph.D.)1 Academic College of Tel Aviv Yaffo Postal code 6161001 Tel Aviv, Israel
re
-p
ro
12 Hannah Sennesh st., Holon, 5829202 Israel Email [email protected] Tel. +972-502498585 Fax. +972-39648906
lP
Dr. Mahdi Tarabeih (RN, Ph.D.)
Jo ur
na
Academic College of Tel Aviv Yaffo Postal code 6161001 Tel Aviv, Israel Email [email protected]
Short title:
Grave New World
Number of manuscript pages:22 Number of tables:1 Number of figures:0
1
Corresponding author
Conflict of interests: The authors declare no conflict of interests.
Journal Pre-proof Ethical approval: Before embarking on the study the author obtained an ethical approval by the IRB committee. Statement of funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 1
Corresponding author
Keywords: Death hastening; End-of-life care; Euthanasia; Intensive care; Qualitative
Jo ur
na
lP
re
-p
ro
of
research; terminally ill
Journal Pre-proof
Grave New World: The conspiracy of silence surrounding non-voluntary euthanasia
Dr. Ya'arit Bokek-Cohen (Ph.D.)1 Academic College of Tel Aviv Yaffo
-p
ro
Tel Aviv, Israel
of
Postal code 6161001
re
12 Hannah Sennesh st., Holon, 5829202
lP
Israel
Email [email protected]
na
Tel. +972-502498585
Jo ur
Fax. +972-39648906
Dr. Mahdi Tarabeih (RN, Ph.D.)
Academic College of Tel Aviv Yaffo Postal code 6161001 Tel Aviv, Israel Email [email protected]
Journal Pre-proof
Short title:
Grave New World
Number of manuscript pages:25 Number of tables:1
1
-p
ro
of
Number of figures:0
Corresponding author
re
Conflict of interests: The authors declare no conflict of interests.
lP
Ethical approval: Before embarking on the study the author obtained an ethical approval by the IRB committee.
na
Statement of funding: This research received no specific grant from any funding
Jo ur
agency in the public, commercial, or not-for-profit sectors.
Grave New World:
The conspiracy of silence surrounding non-voluntary euthanasia Abstract
The scholarship of euthanasia indicates that in most cases, to date, non-voluntary euthanasia has been studied where euthanasia is legalized. Findings of these studies demonstrate the 'slippery slope' and reveal that non-voluntary euthanasia is pervasive in these countries. The research is aimed at answering two questions: (1) What are the common death hastening methods? (2) Is the acceptance of active non-voluntary euthanasia related to the legal status of euthanasia? A qualitative study was conducted in ICUs with 51 nurses. All of the interviewees refused to take part in the death hastening cases and did not obey any doctor's instruction that could hasten or cause
Journal Pre-proof death. Therefore, doctors who conducted NVE did it by themselves. The present study provides evidence of the phenomenon of illegal non-voluntary euthanasia as a routine practice by physicians in palliative care units in Israel. Interviews with 15 nurses employed in these units shed light on the means and methods used by these doctors to hasten terminal patients' death. We conclude that Nurses in various end-of-life care units persist in preserving their professional integrity and refuse to obey doctors' instructions for non-voluntary euthanasia. The slippery slope argument has been
of
refuted in this context.
ro
Keywords: Death hastening; End-of-life care; Euthanasia; Qualitative research;
Jo ur
na
lP
re
-p
terminally ill
Background In some countries, euthanasia is one of the solutions offered for patients suffering immense pain. One of the central controversies in end-of-life care surrounds the decision to conduct euthanasia. Opponents to euthanasia often base their arguments on its possible misuse and the potential phenomenon of the „slippery slope‟ (Lewis, 2007). Opponents are concerned that if euthanasia were approved, the practice could be extended to persons who are unable to make decisions independently (Berghs,
Journal Pre-proof Dierckx de Casterlé, & Gastmans, 2005; Kuuppelomäki, 2000; Quaghebeur, de Casterlé, & Gastmans, 2009; Ryynänen, Myllykangas, Viren, & Heino, 2002; Tanida et al., 2002; Terkamo-Moisio et al., 2017; Terkamo-Moisio, Kvist, & Pietilä, 2015; Turla, Ozkara, Ozkanli, & Alkan, 2006-2007; White, Wise, Young, & Hyde, 20082009). Health professionals and medical ethicists who oppose the legalization of voluntary euthanasia claim the slippery slope argument; they hold that this legalization will lead to acceptance of active non-voluntary euthanasia (Enoch, 2001).
of
In the Code of Ethics for Nurses, the American Nurses Association condemns any
ro
intent to end a patient‟s life, even if it is motivated by considerations regarding the
-p
quality of a patient‟s life, respect for autonomy, or compassion (American Nurses
re
Association, 2015). Active euthanasia is a criminal offense in Israel, whether it is voluntary or non-voluntary, and can be penalized with up to 02 years of
lP
imprisonment. This article focuses on cases of non-voluntary euthanasia (henceforth:
na
NVE) concerning dying patients with advanced, incurable disease, who are not expected to recover and sometimes suffer pain, and in some cases carried out with
Jo ur
neither the request nor the consent of the patient and/or their family members. We describe the various common forms of physician-assisted death which are practiced with terminally ill patients, and where there is a conspiracy of silence among the caregivers around this sensitive topic. These actions are performed either actively or passively by withdrawing life sustaining measures (Trankle, 2014). The reasons are the feelings of compassion and identification of physicians with the suffering of the dying patient, and/or their compliance to the family's request for hastening death in order to prevent unnecessary pain and suffering.
Non-voluntary euthanasia (NVE)
Journal Pre-proof The scholarship of euthanasia indicates that in most cases, to date, NVE has been studied in those countries where euthanasia is legalized. Findings of these studies demonstrate the 'slippery slope' and reveal that NVE is pervasive in these countries. According to the Royal Dutch Medical Association, if the patient does not request euthanasia, the termination of his life is juridically a matter of murder or killing, and not of euthanasia (Royal Netherlands Society for the Promotion of Medicine [Royal Dutch Medical Association], Recovery (Association of Nurses and Nursing Aides, the
of
Netherlands, 1988). Despite this jurisprudence, Dutch doctors carry out medical
ro
murder: In a study conducted in the Netherlands by the Remmelink Committee in
-p
1991, it was estimated that some 1,000 patients' death annually was caused or hastened
re
by physicians without any request for euthanasia having been made at all (Magnusson, 2002; Pollard, 2001; van der Maas et al., 1996).
lP
In Australia, death-hastening practices are employed frequently at a clandestine
na
level by a multidisciplinary range of practitioners (Magnusson, 2002, 2004; Pollard, 2001). In about half of the cases, these practices occur without patient consent and
Jo ur
sometimes with nurses and other staff members acting autonomously without instructions from the doctors.21 In one of the surveys it was found that 77% of the physicians who participated in the survey reported withholding or withdrawing treatment, and more than 80% reported intensifying pain alleviation through analgesia with the probability or certainty of hastening death (Löfmark, 2008). Many Australian physicians perform these practices without patient consent (Löfmark, 2008). In New Zealand, non-voluntary euthanasia has been found to occur in almost 90% of the deaths when palliative services were available (Trankle, 2014). In about half of the cases, the physician did not discuss this option with the patient beforehand (Pollard, 2001). According to another estimate, about 20% of the physicians who
Journal Pre-proof carried out death hastening did it without an explicit request from the patient (Kuhse & Singer, 1993; Magnusson, 2002). Another study conducted in 17 European countries estimated that limitation of life-sustaining therapy occurred in about 73% of dying patients (Sprung, Ledoux, Bulow, Lippert, Wennberg, Baras,... & Thijs, 2008). A national survey of more than 3700 UK doctors revealed that about 29% of them reported making decisions that they expected would hasten death (Seale, 2009). There is a secrecy surrounding the topic of euthanasia in countries where it is illegal, which
of
prevents the development of standards for adequate healthcare provision at the end-
ro
of-life, hence societal control becomes very difficult (Smets et al., 2010). For
-p
example, in New Jersey, 73% of the physicians who participated in a survey reported
re
they had used terminal sedation for a patient. More than 90% of them said there were
al., 2004).
lP
specific circumstances under which they would use terminal sedation (Pomerantz et
na
Despite the growing body of survey evidence, remarkably little is known about the methods used by physicians to hasten death in NVE decisions. The present study
out NVE.
Jo ur
aims at filling this gap and exposing the methods used by physicians when carrying
In Israel, the Dying Patient Law forbids taking any direct and active action in order to cause a patient's death (The law of the dying patient, n.d.). The law permits the caregiver to refrain from giving treatment for a terminal illness if the patient so requests and if the patient is suffering unbearable pain. The State of Israel enshrined the subject of euthanasia in The Dying Patient Law 2005: "It is forbidden to take any direct action aimed at killing the patient, whether by action or by assisting with suicide, but it is permissible to refrain from giving the patient treatment for an incurable illness, at his request, provided that he is suffering significant suffering.
Journal Pre-proof Therefore the law distinguishes between two types of care: 'continuous medical treatment', which by nature is given continuously and uninterruptedly (this treatment refers almost exclusively to an artificial respirator), 'cyclic medical treatment', which is given in cycles, where the end of one cycle and the beginning of the next can be clearly discerned. The most common cyclical treatment among the treatments offered at the end of life include: Chemotherapy, radiation therapy, dialysis, or other drugs. The new law permits the physician to refrain from giving treatment to a terminal
of
patient either at the beginning of treatment or to discontinue a cyclical treatment that
ro
has been started. On the other hand, the law prohibits withdrawing continuous
-p
treatment because withdrawing continuous treatment is a direct action that leads to the
re
patient's death."
The rate at which physicians in Israel practice NVE is unknown and is a topic
lP
that has not been investigated due to a conspiracy of silence among caregivers. Hence,
na
the purpose of the present study is twofold: (a) to describe the common methods practiced in order to hasten the death of terminally ill dying patients (b) to examine
Jo ur
the 'slippery slope' argument: i.e. whether the acceptance of active NVE is related to the legal status of euthanasia. According to the slippery slope argument, one would expect very rare cases of NVE in a country where euthanasia is not legalized.
Method The aim of the present report is to describe how physicians hasten the death of terminally ill, dying patients, when they believe there is no prognosis for recovery. The study was approved by the Institutional Review Board of the academic institution in which the authors are employed (The name of the institution is to be disclosed after the blind review process); The Ethics Committee reference number is 2018015.
Journal Pre-proof The study is a phenomenological qualitative study; the
epistemological foundation guiding our
method of qualitative interviewing is the phenomenological‐ hermeneutic approach, formulated by Ricoeur (1976; Ricoeur & Thompson, 2016). Inspired by Ricoeur‟s hermeneutic theory of interpretation, we regarded the lived experience of nurses in intensive care units as a text, which researchers may interpret using his method. Such a method must encompass ontological questions, such as “What Is Being?”. These questions must then be interpreted in the context of the entire text we are considering.
of
This approach aligns with the aims of this study as we consider the work of the nurse
ro
in general, and of nurses in intensive care units in particular, as an ontological text.
-p
The research team is composed of two researchers, a male and a female, senior
re
lecturers who had extensive training in qualitative research methodology and a vast experience in conducting qualitative studies. To obtain data concerning such medical
lP
practices, M.T. )RN, Ph.D.) interviewed face – to-face semi-structured interviews 51
na
nurses who have been employed in intensive care units for at least 20 years. The inclusion criteria for the sample were being a certified nurse and having been
Jo ur
employed in intensive care units for at least two decades. All of the nurses that were invited to take part in the study agreed. The sampling method was snowball and convenience sampling as they are members of the authors' social-professional network. Hence prior to the study the authors have had collegial relationships with the interviewees. Participants knew that the topic of the study is death-hastening practices. The names mentioned in the Results section are alias and are all pseudonyms. Each interview lasted 1-1.5 hours and was carried out at the respondent's home or in an unobtrusive table in a coffee shop. None else besides the researcher and the interviewee was present in the interview. The interviewees received no compensation
Journal Pre-proof for taking part in the study and for being interviewed. Each interview was recorded after obtaining permission from the respondents and then transcribed verbatim. Field notes were taken after each interview. Transcripts were not returned for interviewees for comments and/or corrections. Two data coders coded the narratives and themes were derived from the data and were not identified in advance. The interview with each nurse consisted of the following questions: 1.
Is there a tendency/trend to hasten death for suffering dying patients with no
If yes, then who initiates this action? A senior doctor; a junior doctor; a nurse; a
ro
2.
of
prognosis for recovery in the department where you are employed?
How many cases of preventing gratuitous suffering did you witness over the past
re
3.
-p
senior doctor and a nurse; a junior doctor and a nurse?
year?
How many physicians did you see over the past year trying to prevent gratuitous
lP
4.
5.
na
pain for dying terminal patients?
How many nurses did you see over the past year trying to prevent gratuitous
6.
Jo ur
pain for dying terminal patients? What are the demographic characteristics of the doctors and nurses whom you saw trying to prevent gratuitous pain for dying terminal patients? 7.
Please relate to their religion, level of religiosity, gender, tenure.
8.
What methods for hastening death did these doctors use?
9.
How do you feel when you witness a case of hastening death?
10. Can you please describe in detail one particular case of hastening death for a suffering dying patient which is most memorable to you?
Results
Journal Pre-proof The information reported by the interviewees provides valuable data about the variety of active NVE methods employed by an unknown number of physicians. The respondents told of witnessing 17 senior doctors conducting NVE over the past year, of whom 6 are secular male Jews, 3 are secular female Jews, and 8 of them are secular male Moslems. Table 1 presents the sample characteristics.
Type of
Doctor's
Religion
gender
department
gender
Religion
tenure
NVE witnessed over the past year
M
Jewish
24
2
M
Jewish
21
5
F
Christian
25
1
F
Christian
31
1
Neurosurgical
F
Christian
23
3
M
Jewish
22
2
M
Jewish
21
2
M
Jewish
22
3
M
Jewish
24
1
M
Moslem
25
1
Pediatric intensive
lP
F
Number of
re
Pediatric intensive care
Moslem
Nurse's
na
M
-p
employed
Moslem
Doctor's
of
Nurse's
ro
Nurse's
care Jewish
M
Respiratory
intensive care Jewish
M
Respiratory
Moslem
Jo ur
intensive care
F
intensive care
Moslem
M
Neurosurgical intensive care
Christian
F
Respiratory intensive care
Moslem
M
Respiratory intensive care
Christian
F
Respiratory intensive care
Christian
M
Respiratory intensive care
Journal Pre-proof Moslem
F
Pediatric intensive
M
Jewish
24
1
M
Moslem
25
1
M
Jewish
26
2
M
Jewish
25
1
M
Jewish
26
1
care Moslem
M
Pediatric intensive care
Jewish
M
Respiratory intensive care
Jewish
F
Respiratory intensive care
Jewish
M
Respiratory
of
intensive care
re
-p
ro
Table 1. The sample characteristics
lP
All of the interviewees spoke of the emotional support provided by the staff to the family members of the dying patients who have an advanced and incurable
na
disease. When the staff understands that the patient has reached his last days or hours,
Jo ur
they enable the family free entrance to the department with no time restrictions, in order to allow them to pray and/or say goodbye according to each family's tradition and religion.
All of the interviewees refused to take part in the death hastening cases and did not obey any doctor's instruction that could hasten or cause death. Therefore, doctors who conducted NVE did it by themselves. Three recurrent themes emerged after careful content analysis of the respondents' narratives: (a) God is the one and only entity who can decide on the timing of a patient's death; (b) Nurses experience moral distress as a result of witnessing NVE; and (c) Nurses self-identified with each dying patient and imagined themselves or their family members in such a situation.
Journal Pre-proof
(a)
God is the one and only entity who can decide on the timing of a patient's of
death Most of the interviewees, be they Jewish, Moslem or Christian, repeatedly talked about God as the only entity that may decide about the timing of death. Karim said: "I do not want to make a decision instead of God, this is God's role, He gives life and He takes life and He is the only one to decide and I do not
of
agree to take part in practices of death hastening".
ro
The religious notion of the existence of 'good' angels as well as angels of death
-p
was reflected in Ronit's and Ahmed's narratives. Ronit said: "It is forbidden, you must
re
inform the family and the children of the patient, because they think that doctors are angels who try to help and not angels of death".
lP
Similarly, Ahmed mentioned 'angels of death':
na
"I think that it is forbidden to hasten or cause death; the doctors can promote it by legal actions and not by practicing illegal deeds because they
Jo ur
do not have the right to do it. The doctors are not angels of death and should not make decisions instead of God". Alex said "I will never take part in killing a patient! I am not God! And God is the only one that decides when a patient dies, and not us the nurses and not the doctors!"
(b)
Nurses experience moral distress as a result of witnessing NVE
It was evident that our informants felt personal moral distress stemming from their witnessing NVE. Rana stressed that "this is an inhumane decision and if I were to take part in it, I would have bad feelings and I would not sleep all night!" NVE was
Journal Pre-proof perceived as equivalent to active killing, and none of the interviewees was willing to witness it. Witnessing NVE without active participation also created tension, as Wafa put it: "I do not want to hear about what the doctor does! I do not want to see it! And obviously I do not want to take part in the treatment of a patient whose death is being hastened!" Ashraf told us that when he refused to take part in NVE, he said to the
Nurses imagined themselves or their family members in such a situation
-p
(c)
ro
of
doctor, "I hope you will not do it during my shift here, because I cannot see it".
re
Some respondents stressed that they think of the patients as if they were themselves or their close relatives. For example, Wasim says: "I will not take part in it because I will
lP
never forgive myself, and I always try to think as if the dying patient was myself or
na
one of my family members". Ahmed told us that he asked a senior doctor to imagine that the dying patient was his close relative, and to think what he would do if this was
Jo ur
the case: "I asked him: 'What would you do then? Would you hasten your own family member's death?' And the doctor did not answer …"
Methods of NVE
Some informants told us they were asked by the senior doctor to administer an extra dosage of morphine to a dying patient; however, they refused to do so because they believed this should not be done. The most common procedure for hastening death by the senior doctors is administering pain medication with a possible lethal effect. Physicians increase the dose of morphine meant to provide adequate pain relief to a potentially lethal level. Another common method is administering tranquilizers in an
Journal Pre-proof abusive dosage, or even against medical advice, in order to sedate the patient. Physicians withhold or withdraw treatment because the treatment is perceived as futile, and because only limited benefit can be expected and there are additional reasons to withdraw or withhold treatment. 1.
Reducing the percentage of oxygen per patient from 100% to 21% in the air in the room.
2.
Administering high-dose opioids or other benzodiazepine-relaxing drugs to
Withdrawing any life-saving or life-extending treatment, such as the renewal of
Not performing unnecessary procedures like imaging (chest x-ray every morning
re
4.
-p
intravenous blood pressure medications.
ro
3.
of
relieve suffering and pain.
because the patient is on a respirator – telling the X-ray technician to skip the
Diluting medication and reducing the concentration of the drug that maintains
na
5.
lP
procedure – no need, etc.).
blood pressure or decreasing the rate of administering it. Lowering the number of breaths: Instead of 12-14 breaths per minute, decreasing
Jo ur
6.
to 4-6 breaths per minute. 7.
Lowering PEEP – Positive End Expiratory Pressure. Instead of 10, lowering to 5 or TV-Tidal volume, lowering from 10 to 5. Turn down or turn off all the alarms in the ventilator or monitor alarm so that the family members will not notice any changes.
8.
Silence the alarms and weaken the volume of the beeps in the monitor.
9.
Stop checking vital signs like blood pressure, pulse, temperature and number of breaths every two hours. Instead, check vital signs once every eight hours.
Journal Pre-proof 10. Perform suction once a day for a ventilated patient instead of every four hours or two hours or as needed. 11. Ask the nurses not to explain to the family that there is another alternative treatment, such as dialysis or hemofiltration because the patient is terminal and would not survive such treatments. 12. Not giving antibiotics because there is no chance. 13. Not changing the method of ventilation to a different method that might help.
of
14. Not doing resuscitation as if it were written: Do Not Resuscitate (DNR). Act this
ro
way without a written directive.
-p
15. Offer resuscitation methods and resuscitation time that seem genuine and give a
re
minimum of CPR drugs such as atropine bicarbonate, to give the family the
lP
feeling that the staff is making the maximum effort.
na
Most memorable case of hastening death
We received descriptions of the most memorable cases from the interviewees and we
Jo ur
present hereby four typical cases. What is common to these examples is the deep imprint they left in the nurses' memory due to the perception that the NVE was not 'justified'. It is noteworthy that none of the cases are documented in the patient's medical file and no medical records have been written so that there will be no future legal action, because it was only the senior physician who performed the action. a.
Dan told us about a case where the doctors decided not to provide life-saving care to a 11-year old boy who became paralyzed and had severe brain damage after surgery to remove a Medulloblastoma. They said that there are hardly any beds for children's rehabilitation and this child would probably occupy a bed in
Journal Pre-proof the pediatric department for a long time and then die anyway. Both the child and his family would suffer for a long time until he dies. Dan explained: "The senior doctors in the department decided with the surgeon not to make any change in treatment for 72 hours. If the situation does not change, they decided to limit the treatment because there is a problem that the child will occupy a bed for many months. There is no place in the country for rehabilitation and there is no rehabilitation institution that can receive him,
of
because in Israel the number of rehabilitation beds for children is one of the
ro
lowest in the world. The child can stay in hospital and in addition it will be
Zehava told us about a 38-year-old patient who was transferred from a general
re
b.
-p
suffering for the parents and he will eventually die."
hospital in the center of the country with advanced cancer arrived in serious,
lP
sunken condition. After he was admitted, the medication was arranged with
na
adjustment of the dosage. The patient began to improve and woke up after three days. The son asked the staff why this was happening. They told him that he was
Jo ur
about to die and the family should start to organize itself for this. And suddenly he awakens and begins to rally. c.
Orit told us about a 47-year-old man with a glioblastoma brain tumor whose condition was worsening. In a talk with his wife, they asked her to stop all treatments, including corticosteroid therapy, which is important for reducing cerebral edema. Of course, his wife and daughters refused their request, and the patient improved and rallied for two more years.
d.
The age of the patient did not have any effect on the nurses' recoiling from NVE. For example, a terminal patient aged 85 who receives morphine by a morphine pump seems to be suffering although he has received several morphine
Journal Pre-proof supplements. The nurse turned to the senior doctor, claiming that the patient is suffering and additional pain medication should be added again. Then the senior doctor asks the nurse to give some more morphine because it will help him. The nurse argued "I'm afraid to do that. That can kill him and I would never forgive myself for that."
of
Discussion Although there is a large corpus of work about the controversies related to NVE, there
ro
has been no documentation of physicians‟ actual practices of hastening death.
-p
Most of the public and professional debates on this issue focus on the views of
re
doctors and the general public (Terkamo-Moisio et al., 2017). The present study
lP
illuminates the viewpoint of nurses and indicates that the viewpoint and actual conduct of doctors are incongruent with that of the nurses. Our study shows that the most
na
commonly used method of NVE is terminal sedation and overdoses of morphine. Understandably NVE is not a natural death; however, the physicians report the cause of
Jo ur
death as a natural one after committing NVE. Consequently, these cases are neither detectable nor traceable by any legal review. Personal attitudes of physicians toward euthanasia in general, and toward the meaning of life as a terminal patient in particular, shape their daily professional practice, and hence doctors who practice NVE go unpunished. The silence on the part of the nurses makes these doctors unpunishable. Findings of the present inquiry lend support to the claim that there is a similar prevalence of NVE in both types of countries, those that legalized euthanasia as well as those that did not legalize it (Royal Netherlands Society for the Promotion of Medicine [Royal Dutch Medical Association], Recovery (Association of Nurses and Nursing Aides, the Netherlands, 1988). For example, the findings align with the claim
Journal Pre-proof that there is no evidence demonstrating that the Netherlands has a greater rate of nonvoluntary or involuntary euthanasia than other Western countries (Pomerantz et al., 2004). The ANA ethical guidelines emphasize the obligation of the nurse to protect human life and human rights, which include the right to life and the security of a person (Terkamo-Moisio et al., 2017). Nurses are willing to participate in discussions and decision making with the families about the goals of the care (Nelson et al.,
of
2011). It is therefore highly important for nurses to advise each patient, if possible, to
ro
ask about advanced care planning. One of the available alternatives for terminally ill
-p
patients is to receive palliative care at home or in a hospice. This alternative can be
re
offered by the clinical staff during prior conversations with the patients and their family as early as possible after the diagnosis of terminal disease is made, in order to
lP
prepare the family to choose this option of palliative care before they reach the final
na
stage of the dying patient life. Of no less importance is the need to help nurses working in end-of-life care to avoid moral distress. Most nurses experience moral
Jo ur
distress, and the majority of situations that cause nurses to experience such distress are related to end of life issues (Wiegand & Funk, 2012). By reporting methods of NVE in a country that has not legalized the practice, our study offers valuable data-driven information that can inform the debates about the legalization of euthanasia that are currently going on in various countries. The quality of healthcare at the end of life needs monitoring in any kind of society, and especially in countries that have not legalized euthanasia. The present article calls attention to the prevalence of NVE and shows that stricter modes of societal and medical control over euthanasia are needed if euthanasia is not legalized.
Journal Pre-proof Analysis of the nurses' narratives has shown that they preserve the patients' as well as their own professional dignity. The concept of dignity can be interpreted in two ways: (a) other-regarding, by respecting the dignity of patients, and (b) selfregarding, by respecting the nurse's own dignity, or self-respect (Gallagher, 2004). One of the aspects of a nurse's self-respect for dignity is the ability to preserve one's integrity (Gallagher, 2004). Hence, it is of great importance for nurses to avoid cases which cause great distress because of receiving instructions from doctors that are
ro
of
directed at causing patients' death.
-p
Strengths and weaknesses of the study
re
This study is the first in Israel to expose the phenomenon of NVE and collect data on methods for hastening death. In so doing, it contributes to the debate of whether
lP
legalizing euthanasia has the potential to cause a slippery slope effect. Findings
na
suggest that NVE occurs despite the fact that euthanasia has not been legalized in Israel. Hence it refutes the slippery slope logic in the context of euthanasia. Therefore,
Jo ur
the information gathered in this study may be utilized in nursing education and in ethical discussions about medical issues at the end of life at both individual and societal levels (Terkamo-Moisio et al., 2017). It is noteworthy that euthanasia and death hastening are totally forbidden in Judaism as well as in Islam, a prohibition that may explain the interviewees‟ aversion to being involved in such cases. Furthermore, the data was obtained from informants who are all personally acquainted with the authors. This personal familiarity with the authors is likely to have instilled confidence in the interviewees to talk about things that are usually kept secret. The authors evaluate that nurses would not have cooperated in a study of this sensitive topic with researchers who are unfamiliar to them. Nonetheless, the authors
Journal Pre-proof acknowledge the possibility that a social desirability effect might have been at work during the face-to-face interviews, leading respondents to express a more negative attitude toward NVE than their authentic opinion. The very same factor of personal familiarity may have caused a social desirability effect wherein the informants were more likely to be concerned about their image as moral persons and were likely to produce narratives that were aimed at creating a good impression on the researchers. Another study limitation is the relatively small number of interviewees; a larger
of
sample is needed in order to receive more comprehensive data about the practice of
ro
NVE. Therefore, more research is needed in order to illuminate the factors influencing
na
Practical recommendations
lP
re
-p
nurses‟ experiences of NVE and their refusal to obey doctors' instructions.
The article exposes a marked inner conflict between nurses‟ negative attitudes
Jo ur
towards euthanasia and the reality wherein they witness NVE conducted by senior doctors. This conflict creates moral distress among nurses, and hence it is recommended to develop and test strategies to mitigate this moral distress (Nelson et al., 2011). Based on our research findings, we suggest that psychological support should be offered to nurses working in palliative and intensive care units. Also, our recommendation is to build and develop an emotional support system for teams dealing with the treatment of end-of-life patients.
Conclusion
Journal Pre-proof To conclude, the results of this empirical study raise fundamental questions concerning the possibility of legalizing euthanasia, and imply that if euthanasia were legalized, it would still not be supported by Israeli nurses. Nurses in various end-oflife care units persist in preserving their professional integrity and refuse to obey doctors' instructions for NVE. These nurses witness death hastening practices conducted by senior doctors and as a result, tend to feel moral distress. Emotional and psychological support should be offered to nurses who are interested in receiving such
of
help. Doctors should be advised to refrain from instructing nurses to take part in death
Jo ur
na
lP
re
-p
ro
hastening practices.
Journal Pre-proof Declarations - Ethics approval and consent to participate Ethical approval for the research project was secured by the IRB of the Academic College of Tel-Aviv-Jaffa ( Approval serial number 2018015; All respondents signed an informed consent form before the study began.
- Consent to publish
of
All respondents signed a written informed consent form and provided a written
ro
consent that their interview protocols would be published .
-p
- Availability of data and materials
re
The datasets generated and/or analysed during the current study are not publicly available due to the secrecy around the illegal actions taken by the doctors, but are
Jo ur
- Competing interests
na
lP
available from the corresponding author on reasonable request.
The authors declare no conflict of interests.
- Funding The
research
project
received
no
financial
support.
- Authors' Contributions YBC and MT planned the study design YBC prepared the interview guide MT collected the data about death hastening methods and interviewed the respondents YBC and MT conducted the data analysis and interpretation
Journal Pre-proof YBC and MT wrote the Introductory section of the manuscript YBC wrote the Methods section YBC and MT wrote the Results and the Discussion sections YBC and MT approved the submitted draft of the manuscript YBC and MT have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are
-p
ro
of
appropriately investigated, resolved, and the resolution documented in the literature.
Jo ur
na
lP
re
- Acknowledgements N/A
Journal Pre-proof
References American Nurses Association. (ANA). (2015). Code of ethics. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/codeof-ethics-for-nurses/ Berghs, M., Dierckx de Casterlé, B., & Gastmans, C. (2005). The complexity of nurses‟ attitudes toward euthanasia: A review of the literature. Journal of
of
Medical Ethics, 31, 441-446. Enoch, D. (2001). Once you start using slippery slope arguments, you‟re on a very
ro
slippery slope. Oxford Journal of Legal Studies, 21, 629-647.
-p
Gallagher, A. (2004). Dignity and respect for dignity-two key health professional
re
values: Implications for nursing practice. Nursing Ethics, 11(6), 587-599.
lP
Goldney, R. D. (2012). Neither euthanasia nor suicide, but rather assisted death. The Australian and New Zealand Journal of Psychiatry, 43(6), 185-187.
na
Harrington, K. J., Affronti, M. L., Schneider, S. M., Razzak, A. R., & Smith, T. J. (2019). Improving attitudes and perceptions about end-of-life nursing on a
Jo ur
hospital-based palliative care unit. Journal of Hospice & Palliative Nursing, 21(4), 272-279.
Klijn A et al. eds., Regulating physician-negotiated death. Amsterdam: Elsevier, 2001, pp. 11–27. Kuhse, H., & Singer, P. (1993). Voluntary euthanasia and the nurse: An Australian survey. International Journal of Nursing Studies, 30(4), 311-322. Kuuppelomäki, M. (2000). Attitudes of cancer patients, their family members and health professionals toward active euthanasia. European Journal of Cancer Care, 9, 16-21.
Journal Pre-proof Lewis, P. (2007). The empirical slippery slope from voluntary to non‐voluntary euthanasia. The Journal of Law, Medicine & Ethics, 35(1), 197-210. Löfmark, R., Nilstun, T., Cartwright, C., Fischer, S., van der Heide, A., Mortier, F., Norup, M., Simonato, L., Onwuteaka-Philipsen, B. D., & EURELD Consortium. (2008). Physician‟s experiences with end-of-life decision-making: Survey in 6 European countries and Australia. BMC Medinice, 6(4), 1-8. Magnusson, R. S. (2002). Angels of death: Exploring the euthanasia underground.
of
Carlton South, Victoria: Melbourne University Press.
ro
Magnusson, R. S. (2004). Euthanasia: Above ground, below ground. Journal of
-p
Medical Ethics, 30(5), 441-446.
re
Nelson, J. E., Cortez, T. B., Curtis, J. R., Lustbader, D. R., Mosenthal, A. C., Mulkerin, C., Ray, D. E., Bassett, R., Boss, R. D., Brasel, K. J., Campbell, M. L.
lP
Weissman, D. E., Puntillo, K. A., & The IPAL-ICU Project. (2011). Integrating
na
palliative care in the ICU: The nurse in a leading role. Journal of Hospice and Palliative Nursing, 13(2), 89-94.
61-65.
Jo ur
Pollard, B. J. (2001). Can euthanasia be safely legalized? Palliative Medicine, 15(1),
Pomerantz, S. C., Bhatt, H., Brodsky, N. L., Lurie, D., Ciesielski, J., & Cavalieri, T. A. (2004). Physicians' practices related to the use of terminal sedation: Moral and ethical concerns. Palliative & Supportive Care, 2(1), 15-21. Quaghebeur, T., de Casterlé, B. D., & Gastmans, C. (2009). Nursing and euthanasia: A review of argument-based ethics literature. Nursing Ethics, 16, 466-486. Ricoeur P. (1976). Interpretation Theory: Discourse and the Surplus of Meaning . Fort Worth, TX: Texas Christian University Press.
Journal Pre-proof Ricoeur, P., & Thompson, J. B. (2016). Hermeneutics and the human sciences: Essays on language, action and interpretation, 1981. Cambridge: Cambridge UP. Royal Netherlands Society for the Promotion of Medicine [Royal Dutch Medical Association], Recovery (Association of Nurses and Nursing Aides, the Netherlands). (1988). Guidelines for Euthanasia (KNMG). (W. Lagerwey, Trans). Issues in Law & Medicine, 3(4), 429-437.
of
Ryynänen, O-P., Myllykangas, M., Viren M., & Heino, H. (2002). Attitudes towards
ro
euthanasia among physicians, nurses and the general public in Finland. Public
-p
Health, 116(6), 322-331.
re
Seale, C. (2009). Hastening death in end-of-life care: a survey of doctors. Social
lP
science &
na
medicine, 69(11), 1659-1666.
Smets, T., Bilsen, J., Cohen, J., Rurup, M. L., Mortier, F., & Deliens, L. (2010).
Jo ur
Reporting of euthanasia in medical practice in Flanders, Belgium: Cross sectional analysis of reported and unreported cases. Bmj, 341, c5174. doi: https://doi.org/10.1136/bmj.c5174 Sprung, C. L., Ledoux, D., Bulow, H. H., Lippert, A., Wennberg, E., Baras, M., ... & Thijs, L. G. (2008). Relieving suffering or intentionally hastening death: where do you draw the line?. Critical care medicine, 36(1), 8-13.
Journal Pre-proof Tanida, N., Asai, A., Ohnishi, M., Nagata, S. K., Fukui, T., Yamazaki, Y., & Kuhse, H. (2002). Voluntary active euthanasia and the nurse: A comparison of Japanese and Australian nurses. Nursing Ethics, 9, 313-322. Terkamo-Moisio, A., Kvist, T., Kangasniemi, M., Laitila, T., Ryynänen, O. P., & Pietilä, A. M. (2017). Nurses‟ attitudes towards euthanasia in conflict with professional ethical guidelines. Nursing Ethics, 24(1), 70-86. Terkamo-Moisio, A., Kvist T., & Pietilä, A-M. (2015). Multifaceted nature of
of
euthanasia: Perceptions of Finnish registered nurses. Journal of Hospice &
law
of
the
dying
patient.
(n.d.)
Retrieved
from
-p
The
ro
Palliative Nursing, 17(2), 105-112.
re
https://www.health.gov.il/DocLib/16914107.pdf
Trankle, S. A. (2014). Decisions that hasten death: Double effect and the experiences
lP
of physicians in Australia. BMC Medical Ethics, 15(1), 15-26.
na
Turla, A., Ozkara, E., Ozkanli, G., & Alkan, N. (2006-2007). Health professionals‟ attitude toward euthanasia: A cross-sectional study from Turkey. Omega, 54(2),
Jo ur
135-145.
van der Maas, P. J., van ver Wal, G., Haverkate, I., de Graaff, C. L., Kester, J. G., Onwuteaka-Philipsen, B. D., van der Heide, A., Bosma, J. M., & Willems, D. L. (1996). Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. The New England Journal of Medicine, 335, 1699-1705. Velarde-García, J. F., Pulido-Mendoza, R., Moro-Tejedor, M. N., Cachón-Pérez, J. M., & Palacios-Ceña, D. (2016). Nursing and end-of-life care in the intensive care unit: A qualitative systematic review. Journal of Hospice & Palliative Nursing, 18(2), 115-123.
Journal Pre-proof White, K. M., Wise, S. E., Young, R. M., & Hyde, M. K. (2008-2009). Exploring the beliefs underlying attitudes to active voluntary euthanasia in a sample of Australian medical practitioners and nurses: A qualitative analysis. Omega, 58(1), 19-39. Wiegand, D. L., & Funk, M. (2012). Consequences of clinical situations that cause
Jo ur
na
lP
re
-p
ro
of
critical care nurses to experience moral distress. Nursing Ethics, 19(4), 479-487.
Journal Pre-proof Highlights
Non-voluntary euthanasia is pervasive where it is legalized
Common method of non voluntary euthanasia: terminal sedation and morphine
of
overdoses
ro
All of the interviewees refused to take part in death hastening cases
lP
re
-p
Nurses experience moral distress as a result of witnessing non voluntary euthanasia
Jo ur
na
Findings refute the slippery slope argument
Ya'arit Bokek-Cohen, Mahdi Tarabeih PII:
S0897-1897(19)30659-7
DOI:
https://doi.org/10.1016/j.apnr.2020.151245
Reference:
YAPNR 151245
To appear in:
Applied Nursing Research
Received date:
20 September 2019
Revised date:
30 October 2019
Accepted date:
15 February 2020
Please cite this article as: Y. Bokek-Cohen and M. Tarabeih, Grave new world: The conspiracy of silence surrounding non-voluntary euthanasia, Applied Nursing Research(2018), https://doi.org/10.1016/j.apnr.2020.151245
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
© 2018 Published by Elsevier.
Journal Pre-proof
Grave New World: The conspiracy of silence surrounding non-voluntary euthanasia
of
Dr. Ya'arit Bokek-Cohen (Ph.D.)1 Academic College of Tel Aviv Yaffo Postal code 6161001 Tel Aviv, Israel
re
-p
ro
12 Hannah Sennesh st., Holon, 5829202 Israel Email [email protected] Tel. +972-502498585 Fax. +972-39648906
lP
Dr. Mahdi Tarabeih (RN, Ph.D.)
Jo ur
na
Academic College of Tel Aviv Yaffo Postal code 6161001 Tel Aviv, Israel Email [email protected]
Short title:
Grave New World
Number of manuscript pages:22 Number of tables:1 Number of figures:0
1
Corresponding author
Conflict of interests: The authors declare no conflict of interests.
Journal Pre-proof Ethical approval: Before embarking on the study the author obtained an ethical approval by the IRB committee. Statement of funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 1
Corresponding author
Keywords: Death hastening; End-of-life care; Euthanasia; Intensive care; Qualitative
Jo ur
na
lP
re
-p
ro
of
research; terminally ill
Journal Pre-proof
Grave New World: The conspiracy of silence surrounding non-voluntary euthanasia
Dr. Ya'arit Bokek-Cohen (Ph.D.)1 Academic College of Tel Aviv Yaffo
-p
ro
Tel Aviv, Israel
of
Postal code 6161001
re
12 Hannah Sennesh st., Holon, 5829202
lP
Israel
Email [email protected]
na
Tel. +972-502498585
Jo ur
Fax. +972-39648906
Dr. Mahdi Tarabeih (RN, Ph.D.)
Academic College of Tel Aviv Yaffo Postal code 6161001 Tel Aviv, Israel Email [email protected]
Journal Pre-proof
Short title:
Grave New World
Number of manuscript pages:25 Number of tables:1
1
-p
ro
of
Number of figures:0
Corresponding author
re
Conflict of interests: The authors declare no conflict of interests.
lP
Ethical approval: Before embarking on the study the author obtained an ethical approval by the IRB committee.
na
Statement of funding: This research received no specific grant from any funding
Jo ur
agency in the public, commercial, or not-for-profit sectors.
Grave New World:
The conspiracy of silence surrounding non-voluntary euthanasia Abstract
The scholarship of euthanasia indicates that in most cases, to date, non-voluntary euthanasia has been studied where euthanasia is legalized. Findings of these studies demonstrate the 'slippery slope' and reveal that non-voluntary euthanasia is pervasive in these countries. The research is aimed at answering two questions: (1) What are the common death hastening methods? (2) Is the acceptance of active non-voluntary euthanasia related to the legal status of euthanasia? A qualitative study was conducted in ICUs with 51 nurses. All of the interviewees refused to take part in the death hastening cases and did not obey any doctor's instruction that could hasten or cause
Journal Pre-proof death. Therefore, doctors who conducted NVE did it by themselves. The present study provides evidence of the phenomenon of illegal non-voluntary euthanasia as a routine practice by physicians in palliative care units in Israel. Interviews with 15 nurses employed in these units shed light on the means and methods used by these doctors to hasten terminal patients' death. We conclude that Nurses in various end-of-life care units persist in preserving their professional integrity and refuse to obey doctors' instructions for non-voluntary euthanasia. The slippery slope argument has been
of
refuted in this context.
ro
Keywords: Death hastening; End-of-life care; Euthanasia; Qualitative research;
Jo ur
na
lP
re
-p
terminally ill
Background In some countries, euthanasia is one of the solutions offered for patients suffering immense pain. One of the central controversies in end-of-life care surrounds the decision to conduct euthanasia. Opponents to euthanasia often base their arguments on its possible misuse and the potential phenomenon of the „slippery slope‟ (Lewis, 2007). Opponents are concerned that if euthanasia were approved, the practice could be extended to persons who are unable to make decisions independently (Berghs,
Journal Pre-proof Dierckx de Casterlé, & Gastmans, 2005; Kuuppelomäki, 2000; Quaghebeur, de Casterlé, & Gastmans, 2009; Ryynänen, Myllykangas, Viren, & Heino, 2002; Tanida et al., 2002; Terkamo-Moisio et al., 2017; Terkamo-Moisio, Kvist, & Pietilä, 2015; Turla, Ozkara, Ozkanli, & Alkan, 2006-2007; White, Wise, Young, & Hyde, 20082009). Health professionals and medical ethicists who oppose the legalization of voluntary euthanasia claim the slippery slope argument; they hold that this legalization will lead to acceptance of active non-voluntary euthanasia (Enoch, 2001).
of
In the Code of Ethics for Nurses, the American Nurses Association condemns any
ro
intent to end a patient‟s life, even if it is motivated by considerations regarding the
-p
quality of a patient‟s life, respect for autonomy, or compassion (American Nurses
re
Association, 2015). Active euthanasia is a criminal offense in Israel, whether it is voluntary or non-voluntary, and can be penalized with up to 02 years of
lP
imprisonment. This article focuses on cases of non-voluntary euthanasia (henceforth:
na
NVE) concerning dying patients with advanced, incurable disease, who are not expected to recover and sometimes suffer pain, and in some cases carried out with
Jo ur
neither the request nor the consent of the patient and/or their family members. We describe the various common forms of physician-assisted death which are practiced with terminally ill patients, and where there is a conspiracy of silence among the caregivers around this sensitive topic. These actions are performed either actively or passively by withdrawing life sustaining measures (Trankle, 2014). The reasons are the feelings of compassion and identification of physicians with the suffering of the dying patient, and/or their compliance to the family's request for hastening death in order to prevent unnecessary pain and suffering.
Non-voluntary euthanasia (NVE)
Journal Pre-proof The scholarship of euthanasia indicates that in most cases, to date, NVE has been studied in those countries where euthanasia is legalized. Findings of these studies demonstrate the 'slippery slope' and reveal that NVE is pervasive in these countries. According to the Royal Dutch Medical Association, if the patient does not request euthanasia, the termination of his life is juridically a matter of murder or killing, and not of euthanasia (Royal Netherlands Society for the Promotion of Medicine [Royal Dutch Medical Association], Recovery (Association of Nurses and Nursing Aides, the
of
Netherlands, 1988). Despite this jurisprudence, Dutch doctors carry out medical
ro
murder: In a study conducted in the Netherlands by the Remmelink Committee in
-p
1991, it was estimated that some 1,000 patients' death annually was caused or hastened
re
by physicians without any request for euthanasia having been made at all (Magnusson, 2002; Pollard, 2001; van der Maas et al., 1996).
lP
In Australia, death-hastening practices are employed frequently at a clandestine
na
level by a multidisciplinary range of practitioners (Magnusson, 2002, 2004; Pollard, 2001). In about half of the cases, these practices occur without patient consent and
Jo ur
sometimes with nurses and other staff members acting autonomously without instructions from the doctors.21 In one of the surveys it was found that 77% of the physicians who participated in the survey reported withholding or withdrawing treatment, and more than 80% reported intensifying pain alleviation through analgesia with the probability or certainty of hastening death (Löfmark, 2008). Many Australian physicians perform these practices without patient consent (Löfmark, 2008). In New Zealand, non-voluntary euthanasia has been found to occur in almost 90% of the deaths when palliative services were available (Trankle, 2014). In about half of the cases, the physician did not discuss this option with the patient beforehand (Pollard, 2001). According to another estimate, about 20% of the physicians who
Journal Pre-proof carried out death hastening did it without an explicit request from the patient (Kuhse & Singer, 1993; Magnusson, 2002). Another study conducted in 17 European countries estimated that limitation of life-sustaining therapy occurred in about 73% of dying patients (Sprung, Ledoux, Bulow, Lippert, Wennberg, Baras,... & Thijs, 2008). A national survey of more than 3700 UK doctors revealed that about 29% of them reported making decisions that they expected would hasten death (Seale, 2009). There is a secrecy surrounding the topic of euthanasia in countries where it is illegal, which
of
prevents the development of standards for adequate healthcare provision at the end-
ro
of-life, hence societal control becomes very difficult (Smets et al., 2010). For
-p
example, in New Jersey, 73% of the physicians who participated in a survey reported
re
they had used terminal sedation for a patient. More than 90% of them said there were
al., 2004).
lP
specific circumstances under which they would use terminal sedation (Pomerantz et
na
Despite the growing body of survey evidence, remarkably little is known about the methods used by physicians to hasten death in NVE decisions. The present study
out NVE.
Jo ur
aims at filling this gap and exposing the methods used by physicians when carrying
In Israel, the Dying Patient Law forbids taking any direct and active action in order to cause a patient's death (The law of the dying patient, n.d.). The law permits the caregiver to refrain from giving treatment for a terminal illness if the patient so requests and if the patient is suffering unbearable pain. The State of Israel enshrined the subject of euthanasia in The Dying Patient Law 2005: "It is forbidden to take any direct action aimed at killing the patient, whether by action or by assisting with suicide, but it is permissible to refrain from giving the patient treatment for an incurable illness, at his request, provided that he is suffering significant suffering.
Journal Pre-proof Therefore the law distinguishes between two types of care: 'continuous medical treatment', which by nature is given continuously and uninterruptedly (this treatment refers almost exclusively to an artificial respirator), 'cyclic medical treatment', which is given in cycles, where the end of one cycle and the beginning of the next can be clearly discerned. The most common cyclical treatment among the treatments offered at the end of life include: Chemotherapy, radiation therapy, dialysis, or other drugs. The new law permits the physician to refrain from giving treatment to a terminal
of
patient either at the beginning of treatment or to discontinue a cyclical treatment that
ro
has been started. On the other hand, the law prohibits withdrawing continuous
-p
treatment because withdrawing continuous treatment is a direct action that leads to the
re
patient's death."
The rate at which physicians in Israel practice NVE is unknown and is a topic
lP
that has not been investigated due to a conspiracy of silence among caregivers. Hence,
na
the purpose of the present study is twofold: (a) to describe the common methods practiced in order to hasten the death of terminally ill dying patients (b) to examine
Jo ur
the 'slippery slope' argument: i.e. whether the acceptance of active NVE is related to the legal status of euthanasia. According to the slippery slope argument, one would expect very rare cases of NVE in a country where euthanasia is not legalized.
Method The aim of the present report is to describe how physicians hasten the death of terminally ill, dying patients, when they believe there is no prognosis for recovery. The study was approved by the Institutional Review Board of the academic institution in which the authors are employed (The name of the institution is to be disclosed after the blind review process); The Ethics Committee reference number is 2018015.
Journal Pre-proof The study is a phenomenological qualitative study; the
epistemological foundation guiding our
method of qualitative interviewing is the phenomenological‐ hermeneutic approach, formulated by Ricoeur (1976; Ricoeur & Thompson, 2016). Inspired by Ricoeur‟s hermeneutic theory of interpretation, we regarded the lived experience of nurses in intensive care units as a text, which researchers may interpret using his method. Such a method must encompass ontological questions, such as “What Is Being?”. These questions must then be interpreted in the context of the entire text we are considering.
of
This approach aligns with the aims of this study as we consider the work of the nurse
ro
in general, and of nurses in intensive care units in particular, as an ontological text.
-p
The research team is composed of two researchers, a male and a female, senior
re
lecturers who had extensive training in qualitative research methodology and a vast experience in conducting qualitative studies. To obtain data concerning such medical
lP
practices, M.T. )RN, Ph.D.) interviewed face – to-face semi-structured interviews 51
na
nurses who have been employed in intensive care units for at least 20 years. The inclusion criteria for the sample were being a certified nurse and having been
Jo ur
employed in intensive care units for at least two decades. All of the nurses that were invited to take part in the study agreed. The sampling method was snowball and convenience sampling as they are members of the authors' social-professional network. Hence prior to the study the authors have had collegial relationships with the interviewees. Participants knew that the topic of the study is death-hastening practices. The names mentioned in the Results section are alias and are all pseudonyms. Each interview lasted 1-1.5 hours and was carried out at the respondent's home or in an unobtrusive table in a coffee shop. None else besides the researcher and the interviewee was present in the interview. The interviewees received no compensation
Journal Pre-proof for taking part in the study and for being interviewed. Each interview was recorded after obtaining permission from the respondents and then transcribed verbatim. Field notes were taken after each interview. Transcripts were not returned for interviewees for comments and/or corrections. Two data coders coded the narratives and themes were derived from the data and were not identified in advance. The interview with each nurse consisted of the following questions: 1.
Is there a tendency/trend to hasten death for suffering dying patients with no
If yes, then who initiates this action? A senior doctor; a junior doctor; a nurse; a
ro
2.
of
prognosis for recovery in the department where you are employed?
How many cases of preventing gratuitous suffering did you witness over the past
re
3.
-p
senior doctor and a nurse; a junior doctor and a nurse?
year?
How many physicians did you see over the past year trying to prevent gratuitous
lP
4.
5.
na
pain for dying terminal patients?
How many nurses did you see over the past year trying to prevent gratuitous
6.
Jo ur
pain for dying terminal patients? What are the demographic characteristics of the doctors and nurses whom you saw trying to prevent gratuitous pain for dying terminal patients? 7.
Please relate to their religion, level of religiosity, gender, tenure.
8.
What methods for hastening death did these doctors use?
9.
How do you feel when you witness a case of hastening death?
10. Can you please describe in detail one particular case of hastening death for a suffering dying patient which is most memorable to you?
Results
Journal Pre-proof The information reported by the interviewees provides valuable data about the variety of active NVE methods employed by an unknown number of physicians. The respondents told of witnessing 17 senior doctors conducting NVE over the past year, of whom 6 are secular male Jews, 3 are secular female Jews, and 8 of them are secular male Moslems. Table 1 presents the sample characteristics.
Type of
Doctor's
Religion
gender
department
gender
Religion
tenure
NVE witnessed over the past year
M
Jewish
24
2
M
Jewish
21
5
F
Christian
25
1
F
Christian
31
1
Neurosurgical
F
Christian
23
3
M
Jewish
22
2
M
Jewish
21
2
M
Jewish
22
3
M
Jewish
24
1
M
Moslem
25
1
Pediatric intensive
lP
F
Number of
re
Pediatric intensive care
Moslem
Nurse's
na
M
-p
employed
Moslem
Doctor's
of
Nurse's
ro
Nurse's
care Jewish
M
Respiratory
intensive care Jewish
M
Respiratory
Moslem
Jo ur
intensive care
F
intensive care
Moslem
M
Neurosurgical intensive care
Christian
F
Respiratory intensive care
Moslem
M
Respiratory intensive care
Christian
F
Respiratory intensive care
Christian
M
Respiratory intensive care
Journal Pre-proof Moslem
F
Pediatric intensive
M
Jewish
24
1
M
Moslem
25
1
M
Jewish
26
2
M
Jewish
25
1
M
Jewish
26
1
care Moslem
M
Pediatric intensive care
Jewish
M
Respiratory intensive care
Jewish
F
Respiratory intensive care
Jewish
M
Respiratory
of
intensive care
re
-p
ro
Table 1. The sample characteristics
lP
All of the interviewees spoke of the emotional support provided by the staff to the family members of the dying patients who have an advanced and incurable
na
disease. When the staff understands that the patient has reached his last days or hours,
Jo ur
they enable the family free entrance to the department with no time restrictions, in order to allow them to pray and/or say goodbye according to each family's tradition and religion.
All of the interviewees refused to take part in the death hastening cases and did not obey any doctor's instruction that could hasten or cause death. Therefore, doctors who conducted NVE did it by themselves. Three recurrent themes emerged after careful content analysis of the respondents' narratives: (a) God is the one and only entity who can decide on the timing of a patient's death; (b) Nurses experience moral distress as a result of witnessing NVE; and (c) Nurses self-identified with each dying patient and imagined themselves or their family members in such a situation.
Journal Pre-proof
(a)
God is the one and only entity who can decide on the timing of a patient's of
death Most of the interviewees, be they Jewish, Moslem or Christian, repeatedly talked about God as the only entity that may decide about the timing of death. Karim said: "I do not want to make a decision instead of God, this is God's role, He gives life and He takes life and He is the only one to decide and I do not
of
agree to take part in practices of death hastening".
ro
The religious notion of the existence of 'good' angels as well as angels of death
-p
was reflected in Ronit's and Ahmed's narratives. Ronit said: "It is forbidden, you must
re
inform the family and the children of the patient, because they think that doctors are angels who try to help and not angels of death".
lP
Similarly, Ahmed mentioned 'angels of death':
na
"I think that it is forbidden to hasten or cause death; the doctors can promote it by legal actions and not by practicing illegal deeds because they
Jo ur
do not have the right to do it. The doctors are not angels of death and should not make decisions instead of God". Alex said "I will never take part in killing a patient! I am not God! And God is the only one that decides when a patient dies, and not us the nurses and not the doctors!"
(b)
Nurses experience moral distress as a result of witnessing NVE
It was evident that our informants felt personal moral distress stemming from their witnessing NVE. Rana stressed that "this is an inhumane decision and if I were to take part in it, I would have bad feelings and I would not sleep all night!" NVE was
Journal Pre-proof perceived as equivalent to active killing, and none of the interviewees was willing to witness it. Witnessing NVE without active participation also created tension, as Wafa put it: "I do not want to hear about what the doctor does! I do not want to see it! And obviously I do not want to take part in the treatment of a patient whose death is being hastened!" Ashraf told us that when he refused to take part in NVE, he said to the
Nurses imagined themselves or their family members in such a situation
-p
(c)
ro
of
doctor, "I hope you will not do it during my shift here, because I cannot see it".
re
Some respondents stressed that they think of the patients as if they were themselves or their close relatives. For example, Wasim says: "I will not take part in it because I will
lP
never forgive myself, and I always try to think as if the dying patient was myself or
na
one of my family members". Ahmed told us that he asked a senior doctor to imagine that the dying patient was his close relative, and to think what he would do if this was
Jo ur
the case: "I asked him: 'What would you do then? Would you hasten your own family member's death?' And the doctor did not answer …"
Methods of NVE
Some informants told us they were asked by the senior doctor to administer an extra dosage of morphine to a dying patient; however, they refused to do so because they believed this should not be done. The most common procedure for hastening death by the senior doctors is administering pain medication with a possible lethal effect. Physicians increase the dose of morphine meant to provide adequate pain relief to a potentially lethal level. Another common method is administering tranquilizers in an
Journal Pre-proof abusive dosage, or even against medical advice, in order to sedate the patient. Physicians withhold or withdraw treatment because the treatment is perceived as futile, and because only limited benefit can be expected and there are additional reasons to withdraw or withhold treatment. 1.
Reducing the percentage of oxygen per patient from 100% to 21% in the air in the room.
2.
Administering high-dose opioids or other benzodiazepine-relaxing drugs to
Withdrawing any life-saving or life-extending treatment, such as the renewal of
Not performing unnecessary procedures like imaging (chest x-ray every morning
re
4.
-p
intravenous blood pressure medications.
ro
3.
of
relieve suffering and pain.
because the patient is on a respirator – telling the X-ray technician to skip the
Diluting medication and reducing the concentration of the drug that maintains
na
5.
lP
procedure – no need, etc.).
blood pressure or decreasing the rate of administering it. Lowering the number of breaths: Instead of 12-14 breaths per minute, decreasing
Jo ur
6.
to 4-6 breaths per minute. 7.
Lowering PEEP – Positive End Expiratory Pressure. Instead of 10, lowering to 5 or TV-Tidal volume, lowering from 10 to 5. Turn down or turn off all the alarms in the ventilator or monitor alarm so that the family members will not notice any changes.
8.
Silence the alarms and weaken the volume of the beeps in the monitor.
9.
Stop checking vital signs like blood pressure, pulse, temperature and number of breaths every two hours. Instead, check vital signs once every eight hours.
Journal Pre-proof 10. Perform suction once a day for a ventilated patient instead of every four hours or two hours or as needed. 11. Ask the nurses not to explain to the family that there is another alternative treatment, such as dialysis or hemofiltration because the patient is terminal and would not survive such treatments. 12. Not giving antibiotics because there is no chance. 13. Not changing the method of ventilation to a different method that might help.
of
14. Not doing resuscitation as if it were written: Do Not Resuscitate (DNR). Act this
ro
way without a written directive.
-p
15. Offer resuscitation methods and resuscitation time that seem genuine and give a
re
minimum of CPR drugs such as atropine bicarbonate, to give the family the
lP
feeling that the staff is making the maximum effort.
na
Most memorable case of hastening death
We received descriptions of the most memorable cases from the interviewees and we
Jo ur
present hereby four typical cases. What is common to these examples is the deep imprint they left in the nurses' memory due to the perception that the NVE was not 'justified'. It is noteworthy that none of the cases are documented in the patient's medical file and no medical records have been written so that there will be no future legal action, because it was only the senior physician who performed the action. a.
Dan told us about a case where the doctors decided not to provide life-saving care to a 11-year old boy who became paralyzed and had severe brain damage after surgery to remove a Medulloblastoma. They said that there are hardly any beds for children's rehabilitation and this child would probably occupy a bed in
Journal Pre-proof the pediatric department for a long time and then die anyway. Both the child and his family would suffer for a long time until he dies. Dan explained: "The senior doctors in the department decided with the surgeon not to make any change in treatment for 72 hours. If the situation does not change, they decided to limit the treatment because there is a problem that the child will occupy a bed for many months. There is no place in the country for rehabilitation and there is no rehabilitation institution that can receive him,
of
because in Israel the number of rehabilitation beds for children is one of the
ro
lowest in the world. The child can stay in hospital and in addition it will be
Zehava told us about a 38-year-old patient who was transferred from a general
re
b.
-p
suffering for the parents and he will eventually die."
hospital in the center of the country with advanced cancer arrived in serious,
lP
sunken condition. After he was admitted, the medication was arranged with
na
adjustment of the dosage. The patient began to improve and woke up after three days. The son asked the staff why this was happening. They told him that he was
Jo ur
about to die and the family should start to organize itself for this. And suddenly he awakens and begins to rally. c.
Orit told us about a 47-year-old man with a glioblastoma brain tumor whose condition was worsening. In a talk with his wife, they asked her to stop all treatments, including corticosteroid therapy, which is important for reducing cerebral edema. Of course, his wife and daughters refused their request, and the patient improved and rallied for two more years.
d.
The age of the patient did not have any effect on the nurses' recoiling from NVE. For example, a terminal patient aged 85 who receives morphine by a morphine pump seems to be suffering although he has received several morphine
Journal Pre-proof supplements. The nurse turned to the senior doctor, claiming that the patient is suffering and additional pain medication should be added again. Then the senior doctor asks the nurse to give some more morphine because it will help him. The nurse argued "I'm afraid to do that. That can kill him and I would never forgive myself for that."
of
Discussion Although there is a large corpus of work about the controversies related to NVE, there
ro
has been no documentation of physicians‟ actual practices of hastening death.
-p
Most of the public and professional debates on this issue focus on the views of
re
doctors and the general public (Terkamo-Moisio et al., 2017). The present study
lP
illuminates the viewpoint of nurses and indicates that the viewpoint and actual conduct of doctors are incongruent with that of the nurses. Our study shows that the most
na
commonly used method of NVE is terminal sedation and overdoses of morphine. Understandably NVE is not a natural death; however, the physicians report the cause of
Jo ur
death as a natural one after committing NVE. Consequently, these cases are neither detectable nor traceable by any legal review. Personal attitudes of physicians toward euthanasia in general, and toward the meaning of life as a terminal patient in particular, shape their daily professional practice, and hence doctors who practice NVE go unpunished. The silence on the part of the nurses makes these doctors unpunishable. Findings of the present inquiry lend support to the claim that there is a similar prevalence of NVE in both types of countries, those that legalized euthanasia as well as those that did not legalize it (Royal Netherlands Society for the Promotion of Medicine [Royal Dutch Medical Association], Recovery (Association of Nurses and Nursing Aides, the Netherlands, 1988). For example, the findings align with the claim
Journal Pre-proof that there is no evidence demonstrating that the Netherlands has a greater rate of nonvoluntary or involuntary euthanasia than other Western countries (Pomerantz et al., 2004). The ANA ethical guidelines emphasize the obligation of the nurse to protect human life and human rights, which include the right to life and the security of a person (Terkamo-Moisio et al., 2017). Nurses are willing to participate in discussions and decision making with the families about the goals of the care (Nelson et al.,
of
2011). It is therefore highly important for nurses to advise each patient, if possible, to
ro
ask about advanced care planning. One of the available alternatives for terminally ill
-p
patients is to receive palliative care at home or in a hospice. This alternative can be
re
offered by the clinical staff during prior conversations with the patients and their family as early as possible after the diagnosis of terminal disease is made, in order to
lP
prepare the family to choose this option of palliative care before they reach the final
na
stage of the dying patient life. Of no less importance is the need to help nurses working in end-of-life care to avoid moral distress. Most nurses experience moral
Jo ur
distress, and the majority of situations that cause nurses to experience such distress are related to end of life issues (Wiegand & Funk, 2012). By reporting methods of NVE in a country that has not legalized the practice, our study offers valuable data-driven information that can inform the debates about the legalization of euthanasia that are currently going on in various countries. The quality of healthcare at the end of life needs monitoring in any kind of society, and especially in countries that have not legalized euthanasia. The present article calls attention to the prevalence of NVE and shows that stricter modes of societal and medical control over euthanasia are needed if euthanasia is not legalized.
Journal Pre-proof Analysis of the nurses' narratives has shown that they preserve the patients' as well as their own professional dignity. The concept of dignity can be interpreted in two ways: (a) other-regarding, by respecting the dignity of patients, and (b) selfregarding, by respecting the nurse's own dignity, or self-respect (Gallagher, 2004). One of the aspects of a nurse's self-respect for dignity is the ability to preserve one's integrity (Gallagher, 2004). Hence, it is of great importance for nurses to avoid cases which cause great distress because of receiving instructions from doctors that are
ro
of
directed at causing patients' death.
-p
Strengths and weaknesses of the study
re
This study is the first in Israel to expose the phenomenon of NVE and collect data on methods for hastening death. In so doing, it contributes to the debate of whether
lP
legalizing euthanasia has the potential to cause a slippery slope effect. Findings
na
suggest that NVE occurs despite the fact that euthanasia has not been legalized in Israel. Hence it refutes the slippery slope logic in the context of euthanasia. Therefore,
Jo ur
the information gathered in this study may be utilized in nursing education and in ethical discussions about medical issues at the end of life at both individual and societal levels (Terkamo-Moisio et al., 2017). It is noteworthy that euthanasia and death hastening are totally forbidden in Judaism as well as in Islam, a prohibition that may explain the interviewees‟ aversion to being involved in such cases. Furthermore, the data was obtained from informants who are all personally acquainted with the authors. This personal familiarity with the authors is likely to have instilled confidence in the interviewees to talk about things that are usually kept secret. The authors evaluate that nurses would not have cooperated in a study of this sensitive topic with researchers who are unfamiliar to them. Nonetheless, the authors
Journal Pre-proof acknowledge the possibility that a social desirability effect might have been at work during the face-to-face interviews, leading respondents to express a more negative attitude toward NVE than their authentic opinion. The very same factor of personal familiarity may have caused a social desirability effect wherein the informants were more likely to be concerned about their image as moral persons and were likely to produce narratives that were aimed at creating a good impression on the researchers. Another study limitation is the relatively small number of interviewees; a larger
of
sample is needed in order to receive more comprehensive data about the practice of
ro
NVE. Therefore, more research is needed in order to illuminate the factors influencing
na
Practical recommendations
lP
re
-p
nurses‟ experiences of NVE and their refusal to obey doctors' instructions.
The article exposes a marked inner conflict between nurses‟ negative attitudes
Jo ur
towards euthanasia and the reality wherein they witness NVE conducted by senior doctors. This conflict creates moral distress among nurses, and hence it is recommended to develop and test strategies to mitigate this moral distress (Nelson et al., 2011). Based on our research findings, we suggest that psychological support should be offered to nurses working in palliative and intensive care units. Also, our recommendation is to build and develop an emotional support system for teams dealing with the treatment of end-of-life patients.
Conclusion
Journal Pre-proof To conclude, the results of this empirical study raise fundamental questions concerning the possibility of legalizing euthanasia, and imply that if euthanasia were legalized, it would still not be supported by Israeli nurses. Nurses in various end-oflife care units persist in preserving their professional integrity and refuse to obey doctors' instructions for NVE. These nurses witness death hastening practices conducted by senior doctors and as a result, tend to feel moral distress. Emotional and psychological support should be offered to nurses who are interested in receiving such
of
help. Doctors should be advised to refrain from instructing nurses to take part in death
Jo ur
na
lP
re
-p
ro
hastening practices.
Journal Pre-proof Declarations - Ethics approval and consent to participate Ethical approval for the research project was secured by the IRB of the Academic College of Tel-Aviv-Jaffa ( Approval serial number 2018015; All respondents signed an informed consent form before the study began.
- Consent to publish
of
All respondents signed a written informed consent form and provided a written
ro
consent that their interview protocols would be published .
-p
- Availability of data and materials
re
The datasets generated and/or analysed during the current study are not publicly available due to the secrecy around the illegal actions taken by the doctors, but are
Jo ur
- Competing interests
na
lP
available from the corresponding author on reasonable request.
The authors declare no conflict of interests.
- Funding The
research
project
received
no
financial
support.
- Authors' Contributions YBC and MT planned the study design YBC prepared the interview guide MT collected the data about death hastening methods and interviewed the respondents YBC and MT conducted the data analysis and interpretation
Journal Pre-proof YBC and MT wrote the Introductory section of the manuscript YBC wrote the Methods section YBC and MT wrote the Results and the Discussion sections YBC and MT approved the submitted draft of the manuscript YBC and MT have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are
-p
ro
of
appropriately investigated, resolved, and the resolution documented in the literature.
Jo ur
na
lP
re
- Acknowledgements N/A
Journal Pre-proof
References American Nurses Association. (ANA). (2015). Code of ethics. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/codeof-ethics-for-nurses/ Berghs, M., Dierckx de Casterlé, B., & Gastmans, C. (2005). The complexity of nurses‟ attitudes toward euthanasia: A review of the literature. Journal of
of
Medical Ethics, 31, 441-446. Enoch, D. (2001). Once you start using slippery slope arguments, you‟re on a very
ro
slippery slope. Oxford Journal of Legal Studies, 21, 629-647.
-p
Gallagher, A. (2004). Dignity and respect for dignity-two key health professional
re
values: Implications for nursing practice. Nursing Ethics, 11(6), 587-599.
lP
Goldney, R. D. (2012). Neither euthanasia nor suicide, but rather assisted death. The Australian and New Zealand Journal of Psychiatry, 43(6), 185-187.
na
Harrington, K. J., Affronti, M. L., Schneider, S. M., Razzak, A. R., & Smith, T. J. (2019). Improving attitudes and perceptions about end-of-life nursing on a
Jo ur
hospital-based palliative care unit. Journal of Hospice & Palliative Nursing, 21(4), 272-279.
Klijn A et al. eds., Regulating physician-negotiated death. Amsterdam: Elsevier, 2001, pp. 11–27. Kuhse, H., & Singer, P. (1993). Voluntary euthanasia and the nurse: An Australian survey. International Journal of Nursing Studies, 30(4), 311-322. Kuuppelomäki, M. (2000). Attitudes of cancer patients, their family members and health professionals toward active euthanasia. European Journal of Cancer Care, 9, 16-21.
Journal Pre-proof Lewis, P. (2007). The empirical slippery slope from voluntary to non‐voluntary euthanasia. The Journal of Law, Medicine & Ethics, 35(1), 197-210. Löfmark, R., Nilstun, T., Cartwright, C., Fischer, S., van der Heide, A., Mortier, F., Norup, M., Simonato, L., Onwuteaka-Philipsen, B. D., & EURELD Consortium. (2008). Physician‟s experiences with end-of-life decision-making: Survey in 6 European countries and Australia. BMC Medinice, 6(4), 1-8. Magnusson, R. S. (2002). Angels of death: Exploring the euthanasia underground.
of
Carlton South, Victoria: Melbourne University Press.
ro
Magnusson, R. S. (2004). Euthanasia: Above ground, below ground. Journal of
-p
Medical Ethics, 30(5), 441-446.
re
Nelson, J. E., Cortez, T. B., Curtis, J. R., Lustbader, D. R., Mosenthal, A. C., Mulkerin, C., Ray, D. E., Bassett, R., Boss, R. D., Brasel, K. J., Campbell, M. L.
lP
Weissman, D. E., Puntillo, K. A., & The IPAL-ICU Project. (2011). Integrating
na
palliative care in the ICU: The nurse in a leading role. Journal of Hospice and Palliative Nursing, 13(2), 89-94.
61-65.
Jo ur
Pollard, B. J. (2001). Can euthanasia be safely legalized? Palliative Medicine, 15(1),
Pomerantz, S. C., Bhatt, H., Brodsky, N. L., Lurie, D., Ciesielski, J., & Cavalieri, T. A. (2004). Physicians' practices related to the use of terminal sedation: Moral and ethical concerns. Palliative & Supportive Care, 2(1), 15-21. Quaghebeur, T., de Casterlé, B. D., & Gastmans, C. (2009). Nursing and euthanasia: A review of argument-based ethics literature. Nursing Ethics, 16, 466-486. Ricoeur P. (1976). Interpretation Theory: Discourse and the Surplus of Meaning . Fort Worth, TX: Texas Christian University Press.
Journal Pre-proof Ricoeur, P., & Thompson, J. B. (2016). Hermeneutics and the human sciences: Essays on language, action and interpretation, 1981. Cambridge: Cambridge UP. Royal Netherlands Society for the Promotion of Medicine [Royal Dutch Medical Association], Recovery (Association of Nurses and Nursing Aides, the Netherlands). (1988). Guidelines for Euthanasia (KNMG). (W. Lagerwey, Trans). Issues in Law & Medicine, 3(4), 429-437.
of
Ryynänen, O-P., Myllykangas, M., Viren M., & Heino, H. (2002). Attitudes towards
ro
euthanasia among physicians, nurses and the general public in Finland. Public
-p
Health, 116(6), 322-331.
re
Seale, C. (2009). Hastening death in end-of-life care: a survey of doctors. Social
lP
science &
na
medicine, 69(11), 1659-1666.
Smets, T., Bilsen, J., Cohen, J., Rurup, M. L., Mortier, F., & Deliens, L. (2010).
Jo ur
Reporting of euthanasia in medical practice in Flanders, Belgium: Cross sectional analysis of reported and unreported cases. Bmj, 341, c5174. doi: https://doi.org/10.1136/bmj.c5174 Sprung, C. L., Ledoux, D., Bulow, H. H., Lippert, A., Wennberg, E., Baras, M., ... & Thijs, L. G. (2008). Relieving suffering or intentionally hastening death: where do you draw the line?. Critical care medicine, 36(1), 8-13.
Journal Pre-proof Tanida, N., Asai, A., Ohnishi, M., Nagata, S. K., Fukui, T., Yamazaki, Y., & Kuhse, H. (2002). Voluntary active euthanasia and the nurse: A comparison of Japanese and Australian nurses. Nursing Ethics, 9, 313-322. Terkamo-Moisio, A., Kvist, T., Kangasniemi, M., Laitila, T., Ryynänen, O. P., & Pietilä, A. M. (2017). Nurses‟ attitudes towards euthanasia in conflict with professional ethical guidelines. Nursing Ethics, 24(1), 70-86. Terkamo-Moisio, A., Kvist T., & Pietilä, A-M. (2015). Multifaceted nature of
of
euthanasia: Perceptions of Finnish registered nurses. Journal of Hospice &
law
of
the
dying
patient.
(n.d.)
Retrieved
from
-p
The
ro
Palliative Nursing, 17(2), 105-112.
re
https://www.health.gov.il/DocLib/16914107.pdf
Trankle, S. A. (2014). Decisions that hasten death: Double effect and the experiences
lP
of physicians in Australia. BMC Medical Ethics, 15(1), 15-26.
na
Turla, A., Ozkara, E., Ozkanli, G., & Alkan, N. (2006-2007). Health professionals‟ attitude toward euthanasia: A cross-sectional study from Turkey. Omega, 54(2),
Jo ur
135-145.
van der Maas, P. J., van ver Wal, G., Haverkate, I., de Graaff, C. L., Kester, J. G., Onwuteaka-Philipsen, B. D., van der Heide, A., Bosma, J. M., & Willems, D. L. (1996). Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. The New England Journal of Medicine, 335, 1699-1705. Velarde-García, J. F., Pulido-Mendoza, R., Moro-Tejedor, M. N., Cachón-Pérez, J. M., & Palacios-Ceña, D. (2016). Nursing and end-of-life care in the intensive care unit: A qualitative systematic review. Journal of Hospice & Palliative Nursing, 18(2), 115-123.
Journal Pre-proof White, K. M., Wise, S. E., Young, R. M., & Hyde, M. K. (2008-2009). Exploring the beliefs underlying attitudes to active voluntary euthanasia in a sample of Australian medical practitioners and nurses: A qualitative analysis. Omega, 58(1), 19-39. Wiegand, D. L., & Funk, M. (2012). Consequences of clinical situations that cause
Jo ur
na
lP
re
-p
ro
of
critical care nurses to experience moral distress. Nursing Ethics, 19(4), 479-487.
Journal Pre-proof Highlights
Non-voluntary euthanasia is pervasive where it is legalized
Common method of non voluntary euthanasia: terminal sedation and morphine
of
overdoses
ro
All of the interviewees refused to take part in death hastening cases
lP
re
-p
Nurses experience moral distress as a result of witnessing non voluntary euthanasia
Jo ur
na
Findings refute the slippery slope argument