Consultant Editor Brian Nyatanga Editor Laura Glenny Group Classified Manager Daniel Doherty Circulation Director Sally Boettcher Associate Publisher, Medical Education Tracy Cowan Production Manager Larry Oakes Publishing Director Andrew Iafrati Managing Director Anthony Kerr Chief Executive Officer Ben Allen Editorial enquiries: email@example.com Sales enquiries: firstname.lastname@example.org Editorial Board AUSTRALIA Donna Drew Clinical Nurse Consultant in Paediatric Oncology and Palliative Care, Sydney Children’s Hospital Jason Mills University of the Sunshine Coast, Queensland Jane Phillips Professor of Palliative Nursing and Director of the Centre for Cardiovascular and Chronic Care, University of Technology, Sydney BELARUS Anna Garchakova Director, Belarusian Children’s Hospice BELGIUM Tine De Vlieger General Coordinator for Palliative Care, University of Antwerp IRELAND Julie Ling CEO of the European Association for Palliative Care, Our Lady’s Hospice, Dublin ITALY Valentina Biagioli Research Fellow in Nursing and Allied Health Professional Development, Continuing Education and Research, Bambino Gesù Children’s Hospital, Rome, and Lecturer, Campus BioMedico University, Rome NORTHERN IRELAND Sonja McIlfatrick Professor of Nursing, University of Ulster SWITZERLAND Philip Larkin Kristian Gerhard Jebsen Chair of Nursing Palliative Care, Professer, Centre hospitalier universitaire vaudois, University of Lausanne
UGANDA Julia Downing Honorary Professor in Palliative Care, Makerere University, Kampala UNITED KINGDOM Bridget Johnston Professor of Palliative and Supportive Care, Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care, University of Nottingham Daniel Kelly RCN Chair of Nursing Research, Cardiff University Diane Laverty Nurse Consultant in Palliative Care, St Joseph’s Hospice, London Carole Mula Macmillan Nurse Consultant in Palliative Care and Professional Lead Nurse for Division of Clinical Support Services, Christie NHS Foundation Trust, Manchester Brian Nyatanga Senior Lecturer, University of Worcester Dion Smyth Lecturer-Practitioner in Cancer and Palliative Care, Birmingham City University Anna-Marie Stevens Nurse Consultant in Symptom Control and Palliative Care, Royal Marsden NHS Foundation Trust, London UNITED STATES Jennifer Baird Harvard-Wide Pediatric Health Services Research Fellow, Division of Medicine Critical Care, Boston Children’s Hospital Patricia Berry Professor and Director of Hartford Center of Gerontological Nursing Excellence, Oregon Health and Science University
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Assisted dying I
JPN welcomes evidence-based debate on the articles published within the journal, and December’s editorial by the Consultant Editor, Brian Nyatanga stimulated a thorough consideration of the complexity of the topic of assisted dying. Please find a letter to the journal following Nyatanga’s editorial below, alongside Nyatanga’s response. I hope that such discussions serve to further the accessibility of palliative care, alongside stressing its importance, and as ever, I welcome feedback to the journal. Laura Glenny Editor, IJPN
DLetter to the editor ear Editor,
A fundamental principle of choice is that this choice must be well-informed. Unfortunately, considerable information was missing from the recent editorial published in IJPN on assisted dying (AD) (Nyatanga, 2021). Nyatanga’s claim that palliative care is not a panacea is correct—no care process can claim 100% success. However, missing from the editorial was evidence that AD is also not a panacea, with a 6.9% complication rate in Oregon. This statistic does not include instances of prolonged deaths, a problem which has worsened following Oregon’s fourth drug cocktail in 7 years for the use in AD (Oregon Death with Dignity Act, 2022).
There was also no mention of the 118 000 UK patients each year who cannot access expert palliative care (Hospice Care in the UK, 2017), or the many papers that show the difficulties in accessing expert palliative care in countries where AD has been legalised (Arias-Casais et al, 2020; Jordan et al, 2020; Mitchell et al, 2020; Munro et al, 2020). This is a remarkable omission, since claims of bad or painful deaths in the UK are hardly surprising if an average of 323 people each day fail to get the specialist care they need. This oversight is compounded by failing to mention that growth in palliative care services (home care, hospital teams and inpatient units) in Belgium and the Netherlands has stalled since 2012; in contrast, growth in non-AD countries in Western Europe has been faster than AD countries (Arias-Casais et al, 2020). Recent research shows that AD legislatures rank low in their quality of end-of-life care compared with the non-AD countries of UK and Ireland (Finkelstein et al, 2021), and that all AD legislatures have dropped in their rankings since 2015 in the Quality of death Index (The 2015 Quality of Death Index, 2015). The idea that palliative care is a natural companion to AD is contradicted by the fact that two thirds of Oregon hospices in 2012 have refused to have any involvement with AD (Campbell and Cox, 2012). Alongside this, since the recent legalisation of AD in New Zealand, all but one hospice has refused to participate. The experience of Canada in mandating healthcare involvement in AD and Belgium in passing a law to prevent healthcare organisations from refusing to participate, suggests that any belief in the protection of conscientious objection is illusory.
There is no mention that, when surveyed last year, a majority of practising British Medical Association members in the UK were not willing to participate in either assisted suicide or euthanasia (British Medical Association, 2020). This is not surprising, since the detrimental impact of AD on doctors is becoming clearer, with a psychological impact that can persist after the AD in up to a fifth of physicians (Kelly et al, 2019). The impact on nurses is also being recognised (Pesut et al, 2019).
Nyatanga’s exhortation that nurses should be involved in AD ignored the psychological impact of preparing and handing over lethal drugs, checking capacity and compliance, then supporting the patient and the family through what can be a distressing and prolonged death. He also conveniently forgot that it will be doctors who are expected to make all of initial assessments of a patient’s suitability for AD. This is despite the fact that doctors have no means of accurately predicting prognoses, and no training in detecting coercion or manipulation. He makes no mention of the pharmacists who will have to dispense lethal drugs that have never been approved by any drug regulatory authority, or the social care and other professionals who will have to support patients and their families before and after AD. There is no mention of the numbers involved. Canada
International Journal of Palliative Nursing 2022, Vol 28, No 2