My Oral Submission to the New Zealand Health Committee Regarding Physician-assisted Suicide on March 5, 2017

As a nurse and legal consultant in the USA with 47 years of experience in the most challenging areas of medicine such as critical care, oncology, burn unit and hospice, I have seen many of the most challenging cases in medicine. I also have professional and personal experience with suicidal people, including my own 30 year old daughter Marie who died using an assisted suicide technique that she found searching the internet and after a 16 year struggle with drug addiction. I have worked with many suicidal people, including some with terminal illness. To my knowledge, my daughter was the only one lost to suicide.

I have previously submitted written testimony about physician-assisted suicide and I would like to follow up with two crucial issues that I feel must be addressed.

First I will discuss how physician-assisted suicide empowers doctors, not patients. Second, I’ll share a nurse’s perspective.

1. Physician-assisted suicide empowers doctors, not patients.

Society has long insisted that health care professionals adhere to the highest standards of ethics as a form of protection for society. The vulnerability of a sick person and the inability of society to monitor every health care decision or action are powerful motivators to enforce such standards.

However in physician-assisted suicide, unlike any other medical intervention, any licensed doctor of any experience or specialty is granted immunity from “civil or criminal liability or professional disciplinary action for participating in good faith compliance “with an assisted suicide law[1].  The doctor or doctors involved are the ones to decide whether or not the patient is eligible, not the patient.

All the doctor is required to do is fill out a prescription and state forms. The usual standards for caring for a suicidal person including  intensive management[2]  are changed in physician-assisted suicide to “If, in the opinion of the attending physician or the consulting physician, a patient may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment, either physician shall refer the patient for counseling.”[3] (Emphasis added). Not surprisingly, only 3.8% of people using physician-assisted suicide in Oregon were referred for psychiatric evaluation in 2016[4].

This is dangerous medical discrimination in treatment standards for suicidal people.

In addition, since the doctor is not required to be present or examine the patient after death, any complications or other problems must be self-reported by the doctor to the state. Even the death certificate must be falsified to report the death as from natural causes rather than the lethal overdose.[5]  This violates the standards set by the Centers for Disease Control which require accuracy because, among other issues, “The death certificate is the source for State and national mortality and is used to determine which medical conditions receive research and development funding, to set public health goals, and to measure health status at local, State, national, and international levels.”[6]

The  immunity protections and the secrecy of even the minimal self-reporting standards in US assisted suicide laws eliminates the possibility of future potential lawsuits or prosecutions and keeps the myth of “no problems, no abuses” alive.

2. A Nurse’s Perspective

The dangers of the legalization of physician-assisted suicide are especially acute for us nurses. Unlike doctors, we nurses cannot refuse to care for a patient in a situation like assisted suicide unless another willing nurse can be found which can be impossible. If we do refuse, that is considered abandonment and cause for discipline and even termination. And we are necessarily involved when the assisted suicide act occurs in home health, hospice or health care facility even though the prescribing doctor is not required to be there.

And these deaths are not guaranteed quick, painless or even possible in some circumstances. As a new December 21, 2016 Kaiser Health News article revealed, doctors are trying new drugs because the old drugs are becoming too expensive and taking too long to work. Unfortunately, some new alternative drugs have “turned out to be too harsh, burning patients’ mouths and throats, causing some to scream in pain”.[7]

Like most nurses, I have worked over the years with a variety of doctors who are at various points on the spectrum on competency and integrity.

Years ago, I was threatened with termination after I refused to increase a morphine drip “until he stops breathing” on a man who would not stop breathing after his ventilator was removed and no other nurse was available to take over the patient. The patient was presumed to have had a stroke when he did not wake up from sedation after 24 hours. I reported the situation up the chain of command at my hospital but no one supported me. I loved my profession and at that time, I was the sole support of three young children but I knew that nothing was worth betraying the trust of my patients.

I escaped termination that time but I refused to back down. Soon after, every nurse on a medical division of nurses refused to give an overdose to a patient and told the doctor that he would have to give it himself. The doctor cancelled the order.

Legalizing physician-assisted suicide can force nurses like us to leave healthcare, leaving no reliable safe haven for people who don’t want to end their lives.

Does anyone really want to entrust our healthcare system just to people who are comfortable with ending lives? I don’t.

FOOTNOTES

[1] “Oregon Revised Statute. 127.885s.01. Online at: https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.aspx

2 “Evaluation and Treatment of the Suicidal Patient” . American Family Physician. Online at http://www.aafp.org/afp/2012/0315/p602.html

3 “Evaluation and Treatment of the Suicidal Patient” .American Family Physician. Online at http://www.aafp.org/afp/2012/0315/p602.html

4 “Oregon Death with Dignity Act Date Summary” .Online at https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year19.pdf

5 : “Washington state “Death with Dignity Act”. Online at http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct/DeathCertificateInstructions

6 CDC Medical Examiners’ and Coroners’ Handbook on Death Registration and Fetal Death Reporting”. CDC. Online at https://www.cdc.gov/nchs/data/misc/hb_me.pdf

7 “Docs  In Northwest Tweak Aid-In-Dying Drugs To Prevent Prolonged Deaths” by JoNel Aleccia. Kaiser Health News. February 21, 2017. Online at http://khn.org/news/docs-in-northwest-tweak-aid-in-dying-drugs-to-prevent-prolonged-deaths/

My Submission to the AMA Opposing Neutrality on Physician-Assisted Suicide

Amid conflicting reports about whether or not the American Medical Association was going to consider a position of neutrality on physician assisted suicide, I was informed that the AMA’s Council on Ethical and Judicial Affairs was collecting data, position statements, etc. for consideration of assisted suicide and other topics before the June AMA Annual meeting. The deadline for submissions was February 15.

The following is my submission titled “Neutrality on physician assisted suicide also hurts nurses”

Dear AMA,

I have been a registered nurse since 1969. After working in critical care, hospice, home health, oncology, dialysis and other specialties for 45 years, I am currently working as a legal nurse consultant and volunteer as well as spokesperson for the National Association of Pro-Life Nurses. Over the years, I have cared for many suicidal people as well as people who attempt suicide.

I have served on medical and nursing ethics committees, served on disability and nursing boards. I have written and spoken on medical ethics-especially end of life issues-since 1984.

The dangers of the legalization of physician-assisted suicide are especially acute for us nurses. Unlike doctors, we nurses cannot refuse to care for a patient  in a situation like assisted suicide unless another willing nurse can be found which can be impossible. If we do refuse, that is considered abandonment and cause for discipline and even termination. And we are necessarily involved when the assisted suicide act occurs in home health, hospice or health care facility even though the doctor is not required to be there.

marievalko

Marievalko Picture of Marie Valko 1979-2009

As a nurse and the mother of a suicide victim (see picture above), I am alarmed by reports that the AMA is considering a position of neutrality on physician-assisted suicide. I beg you to uphold the legal and ethical standard that medical professionals must not kill their patients or help them kill themselves. Suicide is a tragedy to be prevented if possible, not a civil right.

MY DAUGHTER KILLED HERSELF USING AN ASSISTED SUICIDE TECHNIQUE

In 2009, I lost a beautiful, physically well 30-year-old daughter, Marie, to suicide after a 16-year battle with substance abuse and other issues. Her suicide was like an atom bomb dropped on our family, friends and even her therapists.

Despite all of our efforts to save her, my Marie told me that she learned how to kill herself from visiting suicide/assisted suicide websites and reading Derek Humphry’s book Final Exit. The medical examiner called Marie’s suicide technique “textbook final exit” but her death was neither dignified nor peaceful.

Marie was not mere collateral damage in the controversy over physician-assisted suicide. She was a victim of the physician-assisted suicide movement, seduced by the rhetoric of a painless exit from what she believed was a hopeless life of suffering.

SUICIDE CONTAGION

Adding to our family’s pain, at least two people close to Marie became suicidal not long after her suicide. Luckily, these two young people received help and were saved, but suicide contagion, better known as “copycat suicide”, is a well-documented phenomenon. Often media coverage or publicity around one death encourages other vulnerable people to commit suicide in the same way.

STUDY SHOWS LEGALIZING PHYSICIAN-ASSISTED SUICIDE IS ASSOCIATED WITH AN INCREASE RATE OF TOTAL SUICIDES

A 2015 article in the Southern Medical Journal titled “How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?” came to these conclusions:

“Legalizing PAS has been associated with an increased rate of total suicides relative to other states and no decrease in nonassisted suicides. This suggests either that PAS does not inhibit (nor acts as an alternative to) nonassisted suicide, or that it acts in this way in some individuals but is associated with an increased inclination to suicide in other individuals.”

THE HEALTH AND ECONOMIC COSTS OF SUICIDE

My Marie was one of the almost 37,000 reported US suicides in 2009. In contrast, only about 800 assisted-suicide deaths have been reported in the past 16 years in Oregon, the first state to legalize physician-assisted suicide. According to the Centers for Disease Control (CDC) suicide was the 10th leading cause of death for Americans in 2012, with “More than 1 million people reported making a suicide attempt in the past year” and “More than 2 million adults reported thinking about suicide in the past year.” The CDC estimates that suicide “costs society approximately $34.6 billion a year in combined medical and work loss costs”, not to mention the emotional toll on families.

Obviously our real health-care crisis here is a staggering and increasing rate of suicides, not the lack of enough assisted suicides.

BRITTANY MAYNARD

There was a media frenzy in October 2014 when Brittany Maynard, a young newlywed woman with a brain tumor, announced plans to commit physician-assisted suicide on November 1 and raise money to have physician-assisted suicide legalized in all US states. There was an immediate and unprecedented media frenzy surrounding Ms. Maynard’s tragic story that routinely portrayed her pending assisted suicide as “heroic” and even counting down the days to her suicide. Personally, I thought this looked like a crowd on the street shouting for a suicidal person on a window ledge to jump.

In the end, Brittany hesitated for a day before she went through with her pledge to take the lethal overdose.

Now, assisted suicide supporters even deny that physician-assisted suicide is suicide, insisting that media stories use euphemisms like “aid-in-dying” and “death with dignity” in cases like Ms. Maynard’s to make assisted suicide more palatable to the public. However, this defies common sense when the definition of suicide is the intentional taking of one’s own life.

PHYSICIAN-ASSISTED SUICIDE AND MEDICAL DISCRIMINATION

I have been a registered nurse for 47 years, working in intensive care, oncology, hospice and home health among other specialties. Personally and professionally, I have cared for many people who attempt or consider killing themselves.

Some of these people were old, chronically ill or had disabilities. Some were young and physically healthy. A few were terminally ill. I cared for all of them to the best of my ability without discrimination as to their condition, age, socioeconomic status, race or gender. I will do anything to help my patients — except kill them or help them kill themselves.

Suicide prevention and treatment works, and the standards must not be changed just because some people insist their desire for physician-assisted suicide is rational and even a civil right.

How Secrecy and Immunity Destroy “Safeguards” in Assisted Suicide Laws

Finally this November, a mainstream media source, the Des Moines Register, investigated some of the problems with legalized physician-assisted suicide in other states such as complications during the process, prolonged deaths,  non-existent or incomplete data in assisted suicide and even the “disputed meaning of ‘self-administer’” of the lethal overdose. This is crucial since Iowa is considering an assisted suicide bill in the legislature.

However, the Register’s reporting ignored one of the most dangerous legal problems in assisted suicide laws: immunity for doctors from “civil or criminal liability or professional disciplinary action for participating in good faith compliance” with the assisted suicide law.  In addition, the secrecy and often yearly destruction of even the minimal information self-reported by the doctors as well as  falsified death certificates listing such deaths as natural effectively destroys any pretense of an enforceable law.

This has made enforcement of so-called “safeguards” virtually impossible in states with legalized assisted suicide and affects even a state like my home state of Missouri that has a  law with penalties to prohibit assisted suicide.

THE MISSOURI EXPERIENCE

Missouri’s law against assisted suicide states:

A person commits the crime of voluntary manslaughter if he knowingly assists another in the commission of self-murder.
Mo. Rev. Stat. § 565.023.1

Yet despite years of failure, the pro-assisted suicide forces are again trying this year to get the standard assisted suicide bill passed in the Missouri legislature.

However, enforcement of the current Missouri law has been problematic. In the only case involving a health care professional, just a five years probation plea agreement was reached before a trial despite a nurse admitting she killed the patient, not assisting a suicide.

In 2001, Daillyn Pavia, RN  faced murder charges after she admitted giving a lethal dose of morphine to a new patient who had just had a stroke and was taken off life support.  According to police, Pavia admitted to co-workers that she had “without authorization and within a half-an-hour of taking charge of Julia Dawson as her patient … intentionally (given) Ms. Dawson 15 times the maximum dosage of morphine that had been prescribed” as well as Propofol, a strong sedative, that was not prescribed. The victim’s son defended the nurse’s action, saying it was done out of compassion and should not be prosecuted.

In 2003, 2 years later, nurse Pavia pleaded guilty to voluntary manslaughter and was sentenced to 5 years probation.  Nurse Pavia did not show up at a hearing before the Missouri State Board of Nursing which noted that Pavia was placed “on five years of supervised probation with the special condition that she surrender her nursing license.”

(Ironically, this decision followed on the heels of the decision not to prosecute Dr. Lloyd Thompson, then head of the Vermont Medical Society, for intentionally giving a paralyzing, “life ending drug” to an elderly woman with terminal cancer whose breathing machine had been removed. The family opposed prosecuting the doctor. Instead Thompson was reprimanded by the Vermont Medical Practice Board that required a monitoring and review of his care of all terminally ill patients.  10 years later, Vermont became the third state to legalize physician-assisted suicide.)

I could find only two other cases of people being charged with assisting a suicide in Missouri. One occurred in 1996 when Velma Howard, a woman with ALS died of suffocation in a motel with family members who admitted giving her sleeping medication, alcohol and a plastic bag. The prosecuting attorney later dropped charges against the family members.

The Jacob Runge assisted suicide case in 2010  resulted in a jury acquitting a young man who provided a gun to his emotionally disturbed friend in a self-described mutual suicide pact but said he could not go through with killing himself.

FALLOUT AND CONSEQUENCES

The fallout from these cases, like many others around the country, show that if someone-even a doctor or nurse-claims that they acted out of “mercy” it is unlikely that a person will face more than a slap on the wrist for ending or helping to end an ill or troubled person’s life.

In addition for those of us who are ethical and conscientious nurses, we feel the chilling effect discouraging us from even reporting other health care providers like nurse Pavia in such cases since we may face repercussions ourselves, including firing. There are apparently no real whistleblower protections for nurses (and thus the public) in such cases, especially since these cases routinely garner much media and public sympathy for the perpetrators and routinely result in minimal if any penalties. Conscience rights may not be enough to protect our patients and ourselves.

As a 2014 Medscape (password protected) article titled “Should Nurses Blow the Whistle or Just Keep Quiet?   by a nurse/lawyer author explains with regard to patient safety violations (which, of course, should include reporting the killing of a patient) :

Am I recommending that nurses adopt the “see nothing, hear nothing, speak nothing” attitude? No. I am saying that under current law, it is safer for a nurse not to report than to report. That surprises me, and it may be right- or wrong-minded, but it’s the way it is. (Emphasis added.)

This is exactly what pro-assisted suicide groups like Compassion and Choices could have hoped for when they fashioned the immunity protections and the secrecy of even the minimal self-reporting standards in their assisted suicide laws. Eliminating the possibility of future potential lawsuits or prosecutions is what keeps their myth of “no problems, no abuses” alive.

Unfortunately, that is also what puts all of us and our loved ones at risk, especially when we are at our most vulnerable. With legalized assisted suicide laws now quickly expanding to other states, we must step up our efforts to educate the public and fight against the well-funded and relentless Compassion and Choices machine.

And there is one significant effort that any of us can do.  Consider asking your own doctor or health care provider where he or she stands on assisted suicide and feel free to state your position. If your doctor is in favor of assisted suicide, you might want to consider asking for a referral to another doctor who refuses to provide assisted suicide. The life you save may be your own.

High Priority: Public Comments Needed on ANA’s New Draft Position Paper on Denying Food and Water

Although the American Nurses Association (ANA) claims it represents the over 3 million US nurses, only a tiny fraction of nurses actually belong. ANA does not give out the actual number of members. I used to belong both my state nursing organization as well as the ANA to try to uphold good nursing ethics and conscience rights for nurses. I finally gave up when my state organization would not address even the conscience rights of nurses in the Nancy Cruzan feeding tube case. I gave up on the ANA when I discovered that the ANA opposed a ban on partial birth abortion without notifying its membership. I only found this out when I watched a TV show on politics mentioning the ANA position. I called the ANA public relations department myself to protest both their position and not notifying members like me and resigned.

Yesterday, I received a call from a nurse in another state who sent me the website for public comments due by 5 pm ET 12/1/2016 about a proposed new ANA position on nutrition and hydration at the end of life.

The proposed position paper is 9 pages long and I sent the following comments with the referenced lines as requested. It would have taken me many pages to address all the issues:

Lines 18-24.  In the past, the hospice principle of never prolonging or hastening death at the end of life was paramount. Now, this has been subjugated to a legalized autonomy (even when exercised by a third party) to decide when to hasten death.

However, nurses are professionals whose integrity depends on proper respect for their conscience rights, especially when it comes to decisions about hastening death.  This concern is absent in this draft.

We do have such a provision in Missouri law that states:

Missouri Revised Statutes
Section 404.872.1

Refusal to honor health care decision, discrimination prohibited, when.

404.872. No physician, nurse, or other individual who is a health care provider or an employee of a health care facility shall be discharged or otherwise discriminated against in his employment or employment application for refusing to honor a health care decision withholding or withdrawing life-sustaining treatment if such refusal is based upon the individual’s religious beliefs, or sincerely held moral convictions.

(L. 1992 S.B. 573 & 634 § 7)

Line 88: There is no definition of “severe neurological conditions”.
Line 90 on “Dementia, recognized as a terminal illness associated with anorexia and cachexia”.  As a former hospice nurse and caregiver for my mother until her death as well as a volunteer for people with dementia, this is an alarming and potentially dangerous assertion. No one should have to die by dehydration and indeed many people with dementia can be spoon-fed like my mother until natural death. I have likewise seen several people begging for food or water but denied because of a decision not to place a feeding tube or spoon feed.

Lines 101-104. VSED as described is really assisted suicide and implicitly changes ANA opposition to medically assisted suicide.

Also, in a New York Times article in October titled “The VSED Exit: A Way to Speed Up Dying, Without Asking Permission”, Dr. Timothy Quill (past president of the AAPHM and the doctor arguing for the constitutionality of assisted suicide in the 1997 Vacco v Quill US Supreme Court case) was quoted as claiming that while VSED is “generally quite comfortable at the beginning”, he also states that “You want a medical partner to manage your symptoms,” because “It’s harder than you think.”

How hard?

In 2000, Quill and Dr. Ira Byock (a palliative care doctor who speaks against legalizing physician-assisted suicide while also supporting VSED and terminal sedation) wrote an article titled “Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids” . The patient was a doctor who wanted to die before his symptoms became worse. He was given a morphine drip that had to be increased to total unconsciousness on day 10 because he became “confused and agitated and began having hallucinations”.

Lines 114-115 cite “Psychological, spiritual, or existential suffering, as well as physical suffering” but only say that “Symptom control is imperative” rather than oppose participation in VSED  for people who are not even terminally ill.

Lines 149-150 state that “Decisions about accepting or forgoing nutrition and hydration will be honored including those decisions about artificially delivered nutrition as well as VSED”. This blanket statement destroys the conscience rights of nurses as well as our duty to advocate for our patients’ best interests. (Emphasis added)

Ironically, the ANA’s 2010 position paper on reproductive rights (i.e. abortion) states that:

“Also,nurses have the right to refuse to participate in a particular case on ethical grounds. However, if a client’s life is in jeopardy, nurses are obligated to provide for the client’s safety and to avoid abandonment.” (Emphasis added) Apparently, the ANA is proposing that the right to refuse to participate ends when the death of the patient is deliberately intended.

CONCLUSION

Just this week, it was reported that a union for Australian nurses is backing voluntary euthanasia. The Australian Nursing and Midwifery Federation (SA branch) is even partnering with other Compassion and Choices-style groups in Australia to pass a voluntary euthanasia bill. This could well be our future here in the US if we do not respond.

As nurses and citizens, we need to fight for truly patient-safe health care by responding to groups like the ANA through comments sections like the one above (which ends December 1) and in the media. We must also support and insist on ethical health care providers for ourselves and our loved ones as well as protecting our patients. As much as we can, we can also help state and national organizations that fight against euthanasia.

Especially if you are a nurse, consider joining the National Association of Pro-Life Nurses and following our Facebook page.

Our profession, our patients and even our nation are at stake!

 

 

Caring for Difficult People

As nurses, we have the privilege to get to know and help all kinds of people we might never have had a chance to meet otherwise on a very personal basis. Sometimes we care for them during some of the most stressful times in their lives.

Doctors and nurses are supposed to treat everyone according to the highest medical and ethical standards without regard to race, gender, socioeconomic status, nationality, etc. but, like everyone else, we can find some individuals particularly difficult.

One incident that changed my perspective on caring for difficult people happened many years ago when I was a young nurse.

I used to pride myself on keeping my cool in any tense situation until the day I almost lost it with a difficult patient.

A young man with drug addiction was admitted to our floor and he incessantly and loudly demanded more pain medication from all his doctors and nurses. No one could reason with him.

Then one day, he came up to me and screamed in my face. I couldn’t calm him and, despite my best intentions, I could feel my anger rise and my face turn red.

Suddenly, an unexpected thought flashed through my mind: “This is the face of Jesus!” At that moment, I was looking directly into this young man’s eyes and I felt a wave of empathy.

Although I did not say a word, the young man’s face suddenly changed and he stepped back almost as if he had been struck. He stopped yelling and started talking. In the end, he actually apologized for his behavior and admitted that he needed help. He was never verbally abusive to any of us after that.

I was stunned by this remarkable change and it changed my perspective. As I tell younger nurses now, it is usually easy to care for pleasant people but it is the difficult ones that need us the most and who often can teach us how to really respect every life.

Perhaps there is a lesson here not just for nurses but for everyone in this current climate of anger and division in our society: When we respect and recognize the intrinsic value in every human being, we really do have a chance to achieve a more just and peaceful society.

Canada and Assisted Suicide for Psychiatric Patients

My first husband and the father of my children was a caring man and dedicated psychiatrist who himself eventually became disabled by mental illness. Early in our marriage, I helped him write his medical journal articles and we planned to eventually include me in his psychiatric practice to work with the families of his patients. As a nurse, I always believed that families were ideally the best support system for patients and our goal was to improve the care and outcomes of people with mental illness.

Tragically, my husband’s mental illness worsened despite intensive treatment. He ultimately abandoned our family and lived the next 26 years in and out of hospitals and assisted living places before he died of natural causes in 2014.

Thus I have a unique perspective on the legal, medical and personal aspects of mental illness.

At one point, a family member sympathetically suggested that it might be better for everyone if he committed suicide. I was horrified. You don’t give up on sick people and I told this person that I would do anything in my power to stop him if he tried to kill himself. Suicide would be the ultimate tragedy.

Canada and Its New Assisted Suicide Law

In February 2015, the Canadian Supreme Court ruled unanimously in the Carter v. Canada case to legalize physician-assisted suicide for competent, consenting adults whose suffering is due to a “grievous and irremediable” medical condition and gave Parliament a year to develop a regulatory regime along these “parameters.”

The Parliamentary Special Joint Committee on Physician-Assisted “Dying” suggested that the “grievous and irremediable” criterion includes nonterminal medical conditions, including psychiatric disorders.

The federal government’s Bill C-14, on the other hand, defined “grievous and irremediable” as an “advanced state of irreversible decline in capabilities” in a person for whom “natural death has become reasonably foreseeable.”  The Senate ultimately passed the bill but the controversy about assisted suicide for psychiatric patients is still raging.

In a June 21, 2016 commentary in the Canadian Medical Association Journal “Should assisted dying for psychiatric disorders be legalized in Canada?”, authors Scott Y.H. Kim MD PhD and Trudo Lemmens LLM DCL warn against this.

As they note:

In Belgium and the Netherlands, medical assistance in dying has been provided to people with chronic schizophrenia, posttraumatic stress disorder, severe eating disorders, autism, personality disorders and even prolonged grief.

The authors conclude that:

Because of the necessarily broad criteria used to regulate assisted dying (in Canada), legalizing the practice for psychiatric conditions will likely place already vulnerable patients at risk of premature death.

However, others like Belgium psychiatrist Joris Vandenberghe, MD, PhD disagree:

“I think the current approach taken by the Canadian government is a bit too strict because it doesn’t fully recognize the enormous impact that psychiatric disorders can have on patients,” Dr Vandenberghe told Medscape Medical News. (Emphasis added)

However, even Dr. Vandenberghe recognizes the problems while still calling for more “safeguards”:

“I am generally not opposed to our euthanasia legislation and agree that patients suffering from psychiatric conditions should not be excluded from our legislation. However, extra precautions are urgently needed.

“I’m not happy with the way things work here [in Belgium]. Sometimes euthanasia is used with insufficient reluctance on the part of the healthcare professionals involved. We’re missing opportunities for treatment, and we need more safeguards,” said Dr. Vandenberghe.

So for me, the answer lies in a thorough evaluation of a patient prior to euthanasia. There really is no time pressure in psychiatric disorders, and if you have a multidisciplinary committee involved in the evaluation, you can take care of lot of the concerns we now have about euthanasia in the setting of psychiatric illness.”

The reality is that very few psychological or psychiatric referrals are even now made for anyone considering assisted suicide either in the US or in Europe. The answer is not more “safeguards” for assisted suicide practitioners to disregard while enjoying virtual legal immunity but rather an emphatic “No!” from the public as well the legal and medical systems. We also need an unbiased media to publicly expose the real facts about legalized medical killing.

 Conclusion

I have seen both the legal and medical systems often fail people with mental illness like my ex-husband who desperately need treatment and safety.

On the medical side, I begged for direction from my ex-husband’s doctors about what I could do to help him but I was told that there was nothing I could do or not do since the doctors were seeing him regularly. I was not allowed to even know his diagnosis without his permission.

On the legal side, I had problems getting supervised visitation even after a hostage situation.  Due to almost constant harassment, I had multiple orders of protection violated without adequate legal response. And despite being on mental illness disability, my ex-husband was allowed to file and lose several frivolous lawsuits-until he ran out of money.

It was a heartbreaking situation.

However, I always hoped that my ex-husband would improve so that he could at least have a better relationship with his children. Even though that did not happen, I am grateful that he did not die by suicide, assisted or otherwise.

Unfortunately, my family’s experience is not unique among families with a member who is mentally ill.

If our medical and legal systems are already often failing people with mental illness and their families, how can we allow them the power to “assist” our loved ones’ suicide?

That would be the ultimate betrayal of an already stigmatized and vulnerable group of people.

Protecting Abortion, Ignoring Safety

This is the official statement of the National Association of Pro-life Nurses on the Whole Women’s Health v. Hellerstatd decision of the U.S. Supreme Court:

The National Association of Pro-life Nurses joins the chorus of astonished Americans who are in disbelief that the Supreme Court of the United States has turned their backs on American women who procure abortions in facilities which do not meet the same health and safety standards as other facilities performing similar invasive procedures.

In Whole Women’s Health V. Hellerstadt the Supreme Court has once again sacrificed the health and well-being of women to political correctness in its 5-3 decision. This is the real War on Women. As the American Association of Pro-Life OB Gyns says (see statement below), it is Supreme Stupidity as it drastically reduces the safety of abortion across the United States. If the Texas law and similar other state laws across the country incur an “undue burden” on the abortion industry, do not similar laws governing the safety and health standards of other free-standing clinics also place an undue burden on the operators thereby negating the justification of such laws?

This is a sad day for the health of Americans everywhere with its far reaching implications and for those of us in the medical profession who are forced to observe these tragic decisions. Such is the state of political correctness in America today.

For Immediate Release from The American Association of Pro-Life Obstetricians and Gynecologists:   

SUPREME STUPIDITY:  Common Sense Health and Safety Requirements for Elective Abortion Struck Down by Supreme Court.

As a professional body of 4000 physicians and reproductive health care professionals,   the American Association of Pro-Life Obstetricians and Gynecologists exists to defend both the lives of pregnant women and their unborn children.   AAPLOG is greatly concerned about the impact of the Supreme Court decision in Whole Women’s Health v. Hellerstadt,  the Texas Clinic Regulations case.    By striking down common sense health and safety regulations that apply to all standard surgical procedures,   the Supreme Court has not only taken away the ability of State Governments to regulate the practice of medicine within their borders but has also made elective abortion mills exempt from controls of any kind.

This politically motivated decision  by the Supreme Court will drastically reduce the safety of abortions across the country, as now abortion clinics and abortionists will be accountable to no one for the conditions inside their walls.   Surgical abortion carries all the risks of any other surgery, and offices which perform abortion should have to meet the same safety standards as those who perform any other comparable surgery.   Medical abortion frequently leads to severe hemorrhage resulting in the need for emergency surgery and transfusions.   Today’s Supreme Court ruling means that abortion clinics across the nation are now permitted to be incapable of responding to these known and predictable surgical emergencies.

The people of Texas clearly wanted to protect women who undergo elective abortion from the Gosnell-type situations in which the woman’s life is put in jeopardy by substandard conditions.   The 5 unelected Justices in the Supreme Court today prevented the State of Texas from regulating the practice of medicine within Texas.   

Abortionists do not face the kind of accountability and safety environments in which all other physicians operate.   Today the Supreme Court made abortionists immune from peer accountability and immune from state regulation.    This lack of accountability legally minimizes the safety of women undergoing abortion procedures.

Those who promote elective abortion as a “medical” procedure desire the status of medicine, without the responsibility of patient safety or accountability.  This Supreme Court decision puts abortionists and their substandard practices above the law.   This decision will effectively allow abortionists to practice without meeting basic safety requirements.   If the Supreme Court really cared about women’s health, this was an exceedingly stupid decision.

 The American Association of Pro-Life Obstetricians and Gynecologists is a professional organization of over 4000 Reproductive Health Care physicians, midwives and others across the country.   AAPLOG exists to provide an evidence based defense of both the pregnant woman and her unborn child.  

media@aaplog.org

Communciations@aaplog.org

Office:  202 230-0997

My Submission to the New Zealand Parliment on Physician-assisted Suicide

On January 30, 2016, I wrote this submission to the New Zealand Parliament’s Health Committee. Today I received an email that it was accepted.

Here is my submission:

Please Reject Physician-assisted Suicide by Nancy Valko, RN ALNC

Nancy Valko, RN ALNC

I have been a registered nurse in the US since 1969. After working in critical care, hospice, home health, oncology, dialysis and other specialties for 45 years, I am currently working as a legal nurse consultant and volunteer. Over the years, I have cared for many suicidal people as well as people who attempt suicide.

I have served on medical and nursing ethics committees, served on disability and nursing boards. I have written and spoken on medical ethics-especially end of life issues-since 1984.

Submission

marievalko Picture of Marie Valko 1979-2009

As a nurse and the mother of a suicide victim, I am alarmed to learn that New Zealand is considering the legalization of physician-assisted suicide. I beg you to uphold the legal and ethical standard that the medical profession must not kill their patients or help them kill themselves. Suicide is a tragedy to be prevented if possible, not a civil right. I am also willing to make an oral submission to the New Zealand parliament.

My Daughter Marie Killed Herself Using an Assisted Suicide Technique

In 2009, I lost a beautiful, physically well 30-year-old daughter, Marie, to suicide after a 16-year battle with substance abuse and other issues. Her suicide was like an atom bomb dropped on our family, friends and even her therapists.

Despite all of our efforts to save her, my Marie told me that she learned how to kill herself from visiting suicide/assisted suicide websites and reading Derek Humphry’s book Final Exit. The medical examiner called Marie’s suicide technique “textbook final exit” but her death was neither dignified nor peaceful.

Marie was not mere collateral damage in the controversy over physician-assisted suicide. She was a victim of the physician-assisted suicide movement, seduced by the rhetoric of a painless exit from what she believed was a hopeless life of suffering.

Suicide Contagion

Adding to our family’s pain, at least two people close to Marie became suicidal not long after her suicide. Luckily, these two young people received help and were saved, but suicide contagion, better known as “copycat suicide”, is a well-documented phenomenon. Often media coverage or publicity around one death encourages other vulnerable people to commit suicide in the same way.

Study Shows Legalizing Physician-Assisted Suicide is Associated with an increased rate of Total Suicides

A recent article in the Southern Medical Journal titled “How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?” came to these conclusions:

“Legalizing PAS has been associated with an increased rate of total suicides relative to other states and no decrease in nonassisted suicides. This suggests either that PAS does not inhibit (nor acts as an alternative to) nonassisted suicide, or that it acts in this way in some individuals but is associated with an increased inclination to suicide in other individuals.”

The Health and Economic Costs of Suicide

My Marie was one of the almost 37,000 reported US suicides in 2009. In contrast, only about 800 assisted-suicide deaths have been reported in the past 16 years in Oregon, the first state to legalize physician-assisted suicide. According to the Centers for Disease Control (CDC) suicide was the 10th leading cause of death for Americans in 2012, with “More than 1 million people reported making a suicide attempt in the past year” and “More than 2 million adults reported thinking about suicide in the past year.” The CDC estimates that suicide “costs society approximately $34.6 billion a year in combined medical and work loss costs”, not to mention the emotional toll on families.

Obviously our real health-care crisis here is a staggering and increasing rate of suicides, not the lack of enough assisted suicides.

Brittany Maynard

There was a media frenzy in October 2014 when of Brittany Maynard, a young newlywed woman with a brain tumor, announced plans to commit physician-assisted suicide on November 1 and raise money to have physician-assisted suicide legalized in all US states. There was an immediate and unprecedented media frenzy surrounding Ms. Maynard’s tragic story that routinely portrayed her pending assisted suicide as “heroic” and even counting down the days to her suicide. Personally, I thought this looked like a crowd on the street shouting for a suicidal person on a window ledge to jump.

In the end, Brittany hesitated for a day before she went through with her pledge to take the lethal overdose.

Now, assisted suicide supporters even deny that physician-assisted suicide is suicide, insisting that media stories use euphemisms like “aid-in-dying” and “death with dignity” in cases like Ms. Maynard’s to make assisted suicide more palatable to the public. However, this defies common sense when the definition of suicide is the intentional taking of one’s own life.

Physician-assisted Suicide and Medical Discrimination

I have been a registered nurse for 46 years, working in intensive care, oncology, hospice and home health among other specialties. Personally and professionally, I have cared for many people who attempt or consider killing themselves.

Some of these people were old, chronically ill or had disabilities. Some were young and physically healthy. A few were terminally ill. I cared for all of them to the best of my ability without discrimination as to their condition, age, socioeconomic status, race or gender. I will do anything to help my patients — except kill them or help them kill themselves.

Suicide prevention and treatment works, and the standards must not be changed just because some people insist their desire for physician-assisted suicide is rational and even a civil right

What Is-Or Should Be- the Future of Nursing?

In a recent Medscape News article “Back to the Future of Nursing: What Progress Have We Made?” , Laura A. Stokowski, RN, MS reported on the results five years after the national Institutes of Medicine (IOM) issued a 2010 report titled “The Future of Nursing: Leading Change, Advancing Health” that was designed to be:

“a wake-up call that exposed the many barriers that prevented the nursing profession from contributing fully to the healthcare system: an aging workforce, regulatory restrictions on nursing practice, fragmentation of healthcare, limited capacity of the nursing education system, and lack of workforce data. It was also a catalyst for finding solutions to these problems.”

The followup report titled “Assessing Progress on the Institute of Medicine Report The Future of Nursing” came out in December 2015 and reported only some progress in their key questions:

  -Have scope-of-practice barricades been pushed aside? Are nurses being permitted to practice to the full extent of their education and licensure?

-Are more nurses earning baccalaureate, master’s, and doctoral degrees?

-Are new graduate nurses being transitioned to the profession more safely and effectively through nurse residency programs?

-Does the ethnic composition of the nursing workforce more closely match the level of diversity in the general population?

-Have opportunities expanded for leadership and interprofessional collaboration in healthcare?

If you are a nurse and were unaware of all this, you are not alone. As a full-time ICU nurse, neither I nor my fellow nurses were aware of this study at that time. The only change we noticed was when our hospital suddenly announced  that every RN must have a BSN by 2021 or be terminated.

I wish we had been asked for our input!

WILL MORE DEGREES, DIVERSITY AND EXPANDED RESPONSIBILITIES REALLY HELP NURSING?

Instead of the IOM focus on these issues, I would propose  at least four measures to really help the majority of us who work in health care institutions to provide the quality care we want for our patients as well as to reduce the stresses of nurses that often lead to burnout and quitting the profession.

 1. Consider bringing back the head nurse

When I started nursing over 47 years ago, we had head nurses who knew the patients, doctors and staff by working with them daily to make sure care was coordinated, staffing was adequate,  and problems were addressed quickly.

Now we have managers and other administrators who often are not RNs and who are often rarely seen or available because of endless meetings. The formerly close working relationships with head nurses have now become almost adversarial relationships with managers as cost containment measures, endless new policies based on legal risk, mandated government regulations, inadequate staffing etc., grind down nurses.

 2. Try retention incentives instead of signup bonuses

Years ago when there was a nursing shortage, signup bonuses were offered to potential nurse employees. I was asked by a director of nurses if I thought the bonuses were high enough.

I told this director that it might be better to try retention bonuses since the newly employed nurses we trained often left after the required year of service to get a signup bonus at another hospital. This wasted the money and time used to assign a precepting nurse to support the temporary new nurse during the weeks-long orientation to our hospital policies and procedures.

A retention bonus would help keep our good, experienced nurses who were already familiar with the doctors, other staff, departments and hospital policies. Such nurses are also often excellent resources for the rest of the staff. This could help prevent some mistakes caused by inexperience or unfamiliarity. In addition, such bonuses could also save money  and increase staff morale by reducing a high turnover rate.

3. Don’t automatically force nurses to get a BSN (bachelor’s degree in nursing)

As I wrote in my March blog “Is it Time for a Two-Track Nursing Education System?”, there is a lack of openings in many BSN programs, not to mention the time stresses and money involved in trying to coordinate full-time 12 hour hospital shifts while  caring for a family and taking classes on a deadline.

Yet there will always a need for excellent bedside nurses who strive to improve their skills, whether or not they decide to pursue a BSN. I believe that it should be a choice, not a requirement, to seek an advanced degree only in nursing.

In the meantime, I believe we should improve basic nursing education, especially by increasing clinical experience and providing mentoring to new graduates.

4. Good nurses deserve to have both conscience and whistle blower rights respected

An April, 2016  Medscape News article “Two Nurses Who Spoke Up, Lost Their Jobs, and Sued”  chronicled the years-long battle of 2 nurses who discovered and reported patient safety problems at their hospitals and lost their jobs as a result of their patient advocacy efforts. Unfortunately, being a good nurse does not automatically provide job security or protection.

Good nurses need both conscience and whistle blower rights protected. Despite rapid changes in historic ethical  and legal principles involving life-termination and abortion issues, most nurses still don’t want to actively participate. Neither do most nurses want to be intimidated from reporting medical incompetence or serious violations of standards involving patient safety.

However, good nurses often find themselves  at risk of harassment or even termination if they refuse to participate in deliberate life-ending decisions or refuse to ignore actual or potential harms to their patients.

Unfortunately, the American Nurses Association and state boards of nursing do not offer much help to nurses in such difficult situations. As the Medscape News article states, even though one nurse cited documents from the American Nurses Association (ANA) code of ethics  which say that nurses have a professional responsibility to protect patient safety:

 “The tricky part—and this is where an experienced attorney is helpful—is understanding the ins and outs of state laws that describe the exceptions to “at will” employment. If an employee reports a patient safety problem and/or is a member of a protected class (older, or a minority), the employer will probably try to prove that the employee was fired for another reason—poor performance, for example. A court will weigh the evidence and decide whether the public policy at issue is more important than upholding the doctrine of at-will employment.”

CONCLUSION

Nurses share a special bond and I am proud to be part of a truly noble profession.  But we need to be able to speak out without fear to insist on the highest standards to improve our healthcare system for both ourselves and especially our patients’ sake.

Is it Time for a Two-Track Nursing Education System?

In what may be news to most people, a March 6, 2016 Wall Street article “Colleges Lock Horns Over Nursing Programs-Four-year institutions try to prevent community colleges from offering advanced programs” states:

The Institute of Medicine, now part of the nonprofit National Academy of Sciences, in 2010 recommended that 80% of nurses hold bachelor’s degrees by 2020, up from about 50% at the time.

Spurred by the report, as well as incentives in the Affordable Care Act to use more highly credentialed nurses, hospitals are scrambling to bring on new staff with bachelor of science degrees in nursing, or push nurses with associate degrees to upgrade to a BSN. That means additional coursework emphasizing community health, critical thinking and evaluating research, in addition to liberal-arts or general-education classes….

That means nurses like Kristina Spaete, who landed a job as a surgical nurse at Scripps Mercy Hospital in San Diego after completing her associate degree in nursing at a community college last May, could soon find herself back in school.

“I feel selfish if I were to go back and pay a ton of money for school,” said the 35-year-old mother of three, who is hoping she can get a BSN at a community college.
For now, getting into any program is tough. U.S. schools turned away 68,938 qualified applicants from bachelor’s and graduate nursing programs in 2014, according to the American Association of Colleges of Nursing, citing a dearth of faculty, clinical sites and classroom space.

Leaders at community colleges, which now train nurses to the associate-degree level, argue they can help fill a hole in the nursing labor market at a low price. Administrators at four-year colleges counter that community colleges aren’t equipped to teach upper-level nursing courses and say there aren’t enough qualified faculty to go around.

“We have to be responsible in terms of how many students realistically can complete these programs, and how many can get jobs,” said Christine Mallon, assistant vice chancellor of academic programs and faculty development at the California State University System.

Here is the letter to the editor I sent to the Wall Street Journal about the crisis in nursing education.

In 1969, I graduated from one of the first associate degree nursing programs due to limited funds and an intense desire to start my nursing career. Some of my high school classmates chose a 4 year BSN degree but the vast majority of nurses then were three year hospital diploma nurses. Now there are almost no diploma programs which were then considered the “gold standard” for nursing education.

At the time, I felt I received a great nursing education but I also felt I needed more clinical experience so I went to the only hospital in my area to offer a nursing internship. I spent the next year in different divisions: 3 months each on medical and surgical divisions including ICUs, 3 months in operating rooms and 3 months as an elective in the cardiac ICU.

By the end of that year, not only did I gain an enormous amount of knowledge and confidence but I also was able to make the decision that I wanted to be an ICU nurse able to work in any type of ICU. I did achieve my dream and more.

A few years after working, I decided I wanted to learn more and I signed up for a BSN completion course at my own expense since scholarships were few and far between. However, I was disappointed that the program seemed geared to producing administrative nurses rather than clinical nurses. I wanted to be a great bedside nurse so instead, I took courses in music and considered pursuing an economics degree to give me more options.

But now, only a BSN will protect many fine nurses from termination or even finding employment at the beginning of their careers. In addition, the shortage of good, reasonably priced BSN completion programs will probably deter many people from even considering a nursing career.

I propose a 2 track nursing education system.

Those who want to be a great bedside nurse could obtain an associate degree and complete a year of internship as a kind of apprenticeship. This plan would not only give new nurses the support to take on the challenges of a bedside nursing career but also help them discover what kind of nursing fit their capabilities best. Such nurses could advance by becoming certified in their chosen specialties. A BSN completion course would always be available if wanted but not required as it is in many health care institutions today.

Some students would choose a BSN program from the beginning but might also want access to the support of an internship when they begin their nursing careers.
I believe this would produce the dedicated nurses we need both at the bedside and in administrative roles.

And after almost 47 years in nursing after following this plan, I would still choose this career again.

I would like to hear what you think or what ideas you have, especially if you are a nurse yourself!