The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [59]
The Mental Health Capacity Act 2005 (sections 24–26) forms the legal basis for advance directives.
Assisted suicide and euthanasia
Euthanasia is the intentional killing, by act or omission, of a person whose life is thought not to be worth living. Assisted suicide is similar in intentionality but differs in that it involves one person (whether a healthcare professional or not) providing the means for another to end his or her own life, whilst not participating in the act itself (Wyatt 2009). At present, both are illegal in the United Kingdom, despite current campaigns to change the law, and it is, therefore, unlawful for any registered nurse to participate in this process.
It must be remembered, however, that those who approach healthcare professionals with a request for assisted suicide or euthanasia will be doing so from a position of significant vulnerability and deserve compassion and respect. Commonly, requests for assisted suicide or euthanasia stem from a fear of pain, indignity and dependence (Wyatt 2009) and it is imperative to ensure that patients are offered adequate opportunities to express these fears, and the specialist physical, psychosocial and spiritual support necessary to minimize their distress.
Artificial hydration
One of the most contentious issues in day-to-day palliative care practice is that of hydration at the end of life, and clear, compassionate communication with patients and their relatives about this aspect of care is therefore essential, as many will be concerned about the impact of poor oral hydration on themselves or their loved one. There is currently no conclusive research in favour of either giving or withholding artificial hydration in end-of-life care, especially in terms of its impact on the length of remaining life. However, studies of the experiences of hospice nurses suggest that artificial hydration has no benefit and, at worst, may contribute to increased respiratory secretions (see Table 2.1) and oedema elsewhere in the body (Watson et al. 2009) and so most palliative care practitioners usually favour stopping artificial hydration on the grounds of preventing increased symptomatology. It is important that the distress of (most often) the relatives is acknowledged in these situations, and their concerns explored. Once the rationale for discontinuing artificial hydration is offered and the patient and/or relatives have been reassured, it is important to support a decision which serves the best interests of the patient first, and their relatives as well. It may be necessary to negotiate a contract whereby a small amount of artificial hydration is given for an agreed period, on the understanding that this will be discontinued if it is causing distress to the patient. As ever, complex situations require skilled and experienced communication (see Chapter 5).
Table 2.1 Common symptoms observed in the terminal phase of life
Symptom Management changes
Pain Levels of pain may increase, decrease or remain stable. Analgesics may need to be rationalized and/or administered via a different route (e.g. via a subcutaneous syringe pump) as the patient may no longer be able to swallow (for further information, see Chapter 9)
Levels of consciousness, lucidity and respiratory rate will all be commonly altered during the terminal phase. It is important to bear this in mind when assessing the effect and side-effects of analgesic medications
Some discomfort can be caused by immobility and pressure on the skin. If appropriate (i.e. if it will not cause patient or relative distress), the patient should be moved to a pressure-relieving mattress. Otherwise regular skin care should be carried out as tolerated (see Chapter 9 for further information)
Nausea/vomiting