NCQAC Advisory Opinion: NCAO 20.01Death with Dignity (Aid-in-Dying): Role of the Nurse
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Department of Health
Nursing Care Quality Assurance Commission
Advisory Opinion
The Nursing Care Quality Assurance Commission (NCQAC) issues this advisory opinion in accordance with WAC 246-840. An advisory
opinion adopted by the NCQAC is an official opinion about safe nursing practice. The opinion is not legally binding and does not have the force
and effect of a duly promulgated regulation or a declaratory ruling by the NCQAC. Institutional policies may restrict practice further in their
setting and/or require additional expectations to assure the safety of their patient and//or decrease risk.
Title:
Death with Dignity (Aid-in-Dying):
Role of the Nurse
Number:
NCAO 20.01
References:
RCW 18.79 Nursing Care
WAC 246-840 Practical and Registered Nursing
RCW 70.245 Washington Death with Dignity Act
WAC 246-978 Death with Dignity Requirements
EHB 1608, Sec.2, Chapter 102, Laws of 2020
Contact:
Deborah Carlson, MSN, BSEd, RN, CPM
Director of Nursing Practice
Phone:
360 236-4703
Email:
Effective Date:
November 13, 2020
Supersedes:
November 8, 2019
Approved By:
Nursing Care Quality Assurance Commission
Conclusion Statement
Advanced registered nurse practitioners (ARNPs), registered nurses (RNs), and licensed practical
nurses (LPNs) may be involved in providing nursing care, within their scope of practice, to
patients who make the choice to end their life through the Washington State Death with Dignity
Act (RCW 70.245). Nurses remain accountable and responsible for providing compassionate and
comprehensive care to all patients, regardless of their end-of-life choices. Nurses may decline
active participation in the implementation of aid-in-dying, but they remain responsible for the
full scope of end-of-life care including providing information, symptom management, and other
palliative or end-of-life interventions. The advisory opinion clarifies the nursing roles and
responsibilities in palliative and end-of-life care.
Background and Analysis
RCW 70.245 Washington Death with Dignity Act, enacted in 2009, allows an eligible individual
with a terminal diagnosis and prognosis to legally request and obtain medications from a
qualified health care practitioner to end their life. The RCW 70.245 Washington Death with
Dignity Act allows a Doctor of Medicine (MD) or Doctor of Osteopathy (DO) who has primary
responsibility for the care and treatment of the patient with terminal illness to prescribe such
NCQAC Advisory Opinion: NCAO 20.01Death with Dignity (Aid-in-Dying): Role of the Nurse
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medications. The act does not allow an advanced registered nurse practitioner to write a
prescription for this purpose. The WAC 246-978 Death with Dignity Requirements implements
the law. See the Washington State Department of Health Death with Dignity Act webpage for
common questions and answers containing general information about the Death with Dignity
Act. Unfortunately, neither the RCW, the WAC, nor the information page provide guidance for
nurses involved in the care of the patient, beyond the clarification that ARNPs may not prescribe.
This lack of recognition of the direct and intimate role of nurses in the care of patients at the end
of life leaves nurses in a potential moral quandary regarding their responsibilities to patients.
Aid-in-dying is a new area of ethical concern about which public opinion and public policy has
evolved quite rapidly such that professional organizations and individual clinicians are still
evolving their positions. The situation is exacerbated by the role of most nurses as employees of
health care institutions that may have additional policies regarding aid-in-dying. Unlike
physicians who have the option to act as independent practitioners outside their association with
an institution, most nurses are required to practice solely under the auspices of their employer.
Additionally, nurses have their own personal beliefs about the ethical acceptability of aid-in-
dying and their own willingness to be involved. Across the profession, there is a broad plurality
of views that need to be accommodated. Nurses are challenged to define their practice while
negotiating the space among these personal, professional, institutional and legal constraints.
Fortunately, the American Nurses Association’s (ANA) recently published The Nurse's Role
when a Patient Request Medical Aid in Dying (2019) clarifies many of the questions nurses are
asking. The position of the ANA is that although nurses are strictly prohibited by law from
prescribing or administering aid-in-dying medications, they nonetheless have an obligation to
provide all other appropriately supportive care to patients at the end-of-life. This care includes
providing objective information, managing distressing symptoms, coaching family and care
providers in the management of patient care, and remaining engaged, non-judgmental, and
attentive to the evolving needs of the dying and their families. They further suggest that nurses
have an obligation to not only be knowledgeable about this issue, but also to be engaged in
public policy conversations and research to further explore its merits and consequences.
This position is aligned with the ANA’s Code of Ethics for Nurses (2015) and Nursing: Scope
and Standards of Practice (2015). For example, they argue that nurses are not “actively
participating” in aid-in-dying when providing information, supporting discussion, or being
present with a patient. Instead, all these actions are the nurse’s ethical “response to the patient’s
quality-of-life self-assessment” (p. 3) consistent with Interpretive Statement 1.4 of the Code that
nurses “should provide interventions to relieve pain and other symptoms in the dying patient
consistent with palliative care practice standards and may not act with the sole intent to end life”
(ANA, 2015, p. 3). Importantly, this is a significant departure from the previous ANA position
statement aid-in-dying of 2013 that strictly prohibited participation by nurses in aid-in-dying.
This advisory opinion will not reiterate the positions taken in the ANA statement, but refers
readers to that document for further exploration. Nor does this opinion take a position on the
essential question of the acceptability of aid-in-dying itself. At this time, aid-in-dying is legal in
Washington State and, as such, nurses need to be prepared to provide care in this context.
NCQAC Advisory Opinion: NCAO 20.01Death with Dignity (Aid-in-Dying): Role of the Nurse
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This context requires particular consideration of two issues not fully addressed in the ANA
statement: employer restrictions on nursing practice and conscientious objection.
Employer Restrictions on Nursing Practice
The Washington state law allows employers to establish policy related to the implementation of
aid-in-dying within their institutional boundaries (which may include both in-patient, out-patient,
and homecare settings). The vast majority of in-patient settings restrict patients from ingesting
medications that will end their lives; policies for outpatient and homecare settings are more
variable and evolving. A study in the Journal of Pain and Symptom Management (JPSM),
Dignity, Death, and Dilemmas: A Study of Washington Hospices and Physician-Assisted Death
(2014), summarizes the content of hospice policies in Washington State. Examples of policies
include:
• Restricting or allowing staff to be present at the time of patient self-administration of the
medication, as well as the duration between ingestion and death.
• Restricting or allowing staff involvement with the process to obtain life-ending
medication.
• Restricting or allowing providing information about the law.
• Preventing or allowing a patient from ingesting a lethal dose of medication on the
premises of a health care facility.
• Requiring, encouraging, or discouraging the participation of LPNs, RNs, or ARNPs in
the process.
• Restricting or allowing initiating communication and notification of the patient’s
attending physician.
• Restricting or allowing staff to witness necessary legal documents.
Health care institutions may legitimately create policies that are consistent with their philosophy
and mission. Health care entities are prohibited, however, from limiting the provision of
information about Washington’s Death with Dignity Act or information about what relevant
resources are available or how to access those resources. EHB 1608, Sec.2, Chapter 102, Laws of
2020.
The most common and ethically defensible limitation is to not allow nurses to be present at the
time of medication administration. This restriction has several advantages. Since nurses are
legally constrained from administering the life-ending medications, the policy prevents nurses
from being pressured by patients or families to assist in administration—an act that in any other
circumstance would be well within the nurse’s scope of practice. Additionally, it allows nurses
who are ethically opposed to aid-in-dying to avoid needing to explicitly opt-out of this most
active participation in the process. Unfortunately, for nurses who would be comfortable
participating at this stage, it also prevents them from providing support to the patient and family
at a critical moment in the dying trajectory. Nurses, particularly hospice and homecare nurses,
often develop significant empathetic relationships with patients and families over the course of
their care and absence at this time can potentially be experienced by the patient as professional
abandonment. This is a significant departure from the standard hospice commitment to non-
abandonment and the promise to witness with the patient through the dying process. While
physicians might choose to act as independent providers at times like this and be present despite
NCQAC Advisory Opinion: NCAO 20.01Death with Dignity (Aid-in-Dying): Role of the Nurse
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institutional policies, nurses choosing to be present outside their nursing role risk violating
professional boundaries. Again, nurses need to decide for themselves whether the restrictions on
practice imposed by institutional policies are aligned with their vision of professional practice.
Institutional policies that further restrict nursing practice, such as limiting the nurse’s ability to
provide objective and non-judgmental information about legal options or provide counseling and
emotional support as the patient thinks through their end-of-life decisions are ethically
problematic in that they significantly impinge on nursing scope of practice and professional
standards of care. In 2020 the Washington legislature clarified that a health care entity may not
limit a health care provider’s provision of information about and regarding Washington’s death
with dignity act, Chapter RCW 70.245, information about what relevant resources are available
in the community, and how to access those resources for obtaining care of the patient’s choice. A
health care entity may not discharge, demote, suspend, discipline, or otherwise discriminate
against a health care provider for providing such information. EHB 1608, Sec.2, Chapter 102,
Laws of 2020. EHB 1608, Sec.2, Chapter 102, Laws of 2020.
Conscientious Objection
It is broadly accepted that aid-in-dying is a situation in which a nurse may appeal to
conscientious objection to avoid acting in a manner that is contrary to her or his own moral
values. While ensuring that patients receive the beneficial care they desire is a fundamental
ethical value, it is necessarily balanced by the right of health care providers to maintain their own
moral integrity (Magelssen, 2011). “Having moral integrity implies having an internally
consistent set of basic moral ideas and principles and being able to live and act in accordance
with these” (Magelssen, 2011, p. 18). When a nurse finds that actively participating in aid-in-
dying conflicts with deeply held values and judgments, it is reasonable to consider this objection.
(Deeply held values are contrasted with those which as capricious, arbitrary, or situationally
convenient.)
Although there are multiple formulations of the criteria such objections must meet, Brock (2008)
delineates three criteria:
1) The patient is informed of the full range of care option.
2) The patient must be referred to another provider who can provide the services.
3) The refusal must not create an undue burden on the patient.
Interestingly, the Death with Dignity Initiative explicitly does not require physicians to refer
patients requesting aid-in-dying to another provider.
Additionally, it is generally understood that conscientious objection applies to particular acts, not
to patients. Such objections cannot be raised to avoid providing general care for a patient, but
only to withdraw from participating in a specific action. For example, in the common example of
abortion, a nurse may decline to participate in actively implementing a surgical abortion
procedure but may not decline to provide post-operative care to that patient. Conscientious
objection cannot be used as a claim to refuse to care for a patient based on their social standing,
beliefs, or preferences, nor on the bias or prejudice of the nurse.
NCQAC Advisory Opinion: NCAO 20.01Death with Dignity (Aid-in-Dying): Role of the Nurse
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This suggests that the only activity nurses may request to avoid is being present when patients
are ingesting the medications that will end their lives. Given that so many institutions already
restrict nurses from being present anyway, this significantly limits the instances in which nurses
may reasonably claim conscientious objection to avoid providing care to a patient. However,
nurses should be attentive to their own self-presentation and their ability to provide
compassionate and non-judgmental care to a patient who is making a decision that is contrary to
their deeply held beliefs. If other staff are reasonably available and can substitute for the
objecting nurse, it may benefit both the patient and the nurse to make this change. Such an
accommodation, however, does not remove the obligation of the nurse to reflect on the
opportunity for developing a more empathetic and patient-centered stance.
Recommendations
The NCQAC determines that in addition to all standard nursing care the following behaviors are
consistent with the standard of care when providing nursing to patients who have chosen to end
their own life:
• Empathetically explore end-of-life options with the patient and family and link them to
services, other health care providers or resources to meet their needs;
• Explain the law as it currently exists;
• Maintain confidentiality about the end-of-life decision-making;
• Provide palliative care for the patient, including administration of medications and
treatments for pain and other symptom management;
• Follow Physician’s Orders for Life Sustaining Treatment (POLST)/advanced directives;
• Determine and pronounce death;
• Collaborate and consult with health care team members;
• Understand the ethical and moral dilemmas related to aid-in-dying
• Understand professional organizations’ positions related to aid-in-dying;
• Reflect on personal and professional values and request accommodation on the basis of
conscientious objection if needed;
• Understand the employer philosophy, policies, and procedures related to end-of-life
decisions and aid-in-dying;
• Understand institutional policy regarding the presence of nurse when a patient self-
administers a prescribed lethal dose of medication;
• Be involved in policy development within the health care institution and the community.
Nurses who choose not to be involved:
Under the conditions delineated above, nurses may decline to be present when patients are
ingesting medication to end their lives. In this situation, the nurse should:
• Request to be relieved from providing care on the basis of conscientious objection;
• Continue to provide standard supportive and palliative care to ensure the patient’s
comfort and safety and avoid abandonment.
NCQAC Advisory Opinion: NCAO 20.01Death with Dignity (Aid-in-Dying): Role of the Nurse
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• Withdraw only when assured that alternative sources of care are available for the patient
and care has been responsibly transferred to another provider;
• Maintain confidentiality;
• Reflect on self-presentation and the development of a non-judgmental stance to ensure
patients feel respected despite differences in values
• Be involved in policy development within the health care institution and community.
Nurses shall not:
• Administer the medication that will lead to the end of the patient’s life;
• Breach confidentiality of patients exploring or choosing assisted suicide;
• Subject patients or families to disrespectful, judgmental comments or actions because of
their decision choose aid-in-dying
• Subject colleagues to disrespectful comments or actions due to their decision to continue
to provide care to a patient who has chosen aid-in-dying;
• Abandon or refuse to provide comfort and safety measures to patients.
Institutional Policy Constraints:
If institutional policies prohibit staff from participating in the aid-in-dying process with
interested patients, the NCQAC recommends that the patient be referred to their attending
physician, the Washington State Department of Health and/or the patient rights organization, End
of Life Washington, to obtain information and initiate the legal process.
Conclusion
Providing care throughout the dying process to patients choosing to end their life through the
Death with Dignity Act is within the nursing scope of practice and does not violate any
professional norms. However, nurses exploring their obligations to the dying are confronted with
a complex set of considerations. Aid-in-dying is legal in the State of Washington. Professional
nursing standards require that nurses treat the dying with compassion and avoid abandonment.
Individual agencies may have policies that limit nurses’ participation in some end-of-life care.
Individual nurses may have deeply held moral beliefs. All these factors need to be weighed as
the nurse decides how to pursue a particular course of action. Ultimately, nurses must make a
choice that is congruent both with their professional obligations and their own moral integrity.
References
American Nurses Association (ANA) – The Nurse’s role when a patient requests medical aid in
dying. (2019): https://www.nursingworld.org/~49e869/globalassets/practiceandpolicy/nursing-
excellence/ana-position-statements/social-causes-and-health-care/the-nurses-role-when-a-
patient-requests-medical-aid-in-dying-web-format.pdf
Brock D. W. (2008). Conscientious refusal by physicians and pharmacists: who is obligated to
do what, and why? Theoretical Medicine and Bioethics, 29, 187-200.
NCQAC Advisory Opinion: NCAO 20.01Death with Dignity (Aid-in-Dying): Role of the Nurse
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Campbell, C.S. and Black, M.A. (2013). Dignity, Death, and Dilemmas: A Study of Washington
Hospices and Physician-Assisted Death: https://www.jpsmjournal.com/article/S0885-
3924(13)00270-4/abstract
Death with Dignity National Center: https://www.deathwithdignity.org/about/
End of Life Washington: https://endoflifewa.org/
Magelssen, M. (2012). When should conscientious objection be accepted? Journal of Medical
Ethics, 38, 18-21.
Nursing Care Quality Assurance Commission Practice (NCQAC) Advisory Opinions:
https://www.doh.wa.gov/LicensesPermitsandCertificates/NursingCommission/PracticeInformati
on
• Completion of Death Certificates by Advanced Registered Nurse Practitioners
o Guideline – Completion of Death Certificates
• Death, Determination and Pronouncement by Licensed Practical Nurses
• Physician’s Orders for Life-Sustaining Treatment (POLST)
o Frequently Asked Questions about POLST
