Terminal Illness: I Didn't Intend for Charlotte to Die

by PJ King, RN

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Following is a realistic, even likely, scenario. For it I draw on a number of actual experiences I have had as a nurse:

Charlotte has lived for six years in the nursing home where I work. Until recently she has been relatively healthy and has enjoyed life as she finds it, even though she can no longer entirely care for herself. A week ago she became lethargic, at times not even responding when shaken and spoken to. In her more alert moments she complains of general pain. She says she wants to die. Her physician orders some lab tests. The results suggest possibilities, but nothing concrete. Because she is a "no code" no further tests are done. We wait to see what will happen, still uncertain what is happening to her.

Over the next few days her condition worsens. Although she rarely speaks, it is evident that she is in pain. The doctor orders morphine sulfate, 2 mg per hour by IV drip. Charlotte's restlessness ceases.

After a day and a half, the MS doesn't seem to be helping Charlotte as much as it did at first. Despite her poor condition, no one can assert with any confidence that she is dying. And if she is, no one knows if she'll live another day or another month. The doctor writes a new order for MS 5-20 mg an hour, to be regulated at the discretion of the nurse.

Charlotte is my patient tonight. She appears to be having some pain, but shortly after her MS dosage is increased from 2 to 5 mg, she again rests quietly. Her respirations are slow but not severely depressed, so I know she is tolerating the new dosage.

That's the scene. Here are three endings:

  1. Over the next four nights, Charlotte deteriorates. She no longer speaks. She eats less and less until she is not eating at all. As I observe her restlessness return, I increase her morphine dose slightly, wanting to keep her comfortable, and aware that, as long as the dosage is increased gradually, the sky's the limit with morphine. Tolerance will develop, but risk to life does not increase with the amount given, unlike other narcotics. On the fourth night, Charlotte quietly slips away, her family at her bedside.

  2. I have the weekend off. When I return Sunday night, I find that Charlotte has begun talking again, and is able to eat. More blood work is done: her electrolyte levels have improved. By the end of two weeks, she is back to her normal self. The morphine drip was tapered off gradually and now she is on a non-narcotic analgesic, but she does not need it very often.

  3. On the night after the morphine has been increased to 5 mg per hour, I notice Charlotte becoming increasingly restless. She moans when I reposition her. I can almost feel her pain myself. Why not put an end to it? She has repeatedly said to me and others on the staff, "Oh, just let me die." She is breathing slowly now. I adjust the morphine dose to 20 mg an hour, knowing that the drug will depress respirations further. The increase is so sudden I know her body will not be able to accommodate it. Over the next two hours her respirations decrease until she is breathing perhaps once in a minute. And then she stops. I check for a heartbeat, but there is none. She is dead.

I have been that nurse in a number of variations of this story, in both the first and second versions. Until recently the nurse in the third ending would have been convicted of murder, or at least have lost her license to practice nursing.

If I lived in Michigan and were the nurse in the third ending, what would happen to me if this case came to trial today? According to Michigan state law, "[A] person is not guilty of criminal assistance of suicide if that person was administering medications or procedures with the intent to relieve pain and discomfort and not to cause death," even if the treatment "may hasten or increase the risk of death." Kevorkian's defense in his just-concluded trial was that his intention was to relieve suffering, not to end life. In other words, although his intent was to end life, his motivation was (according to him) the desire to "relieve pain and discomfort," a distinction of which the Pontiac jurors were apparently incapable.

I and nurses with whom I work and whom I respect have willingly administered narcotic pain medications to patients, sometimes knowing that the patient's life may be shortened somewhat. We don't want that to happen, yet we are willing to run some slight risk to eliminate or diminish suffering. The Michigan law protects healthcare professionals in these situations. Now are we to understand that doctors and nurses have permission deliberately to end the lives of certain persons in their care, as long as they were motivated by compassion?

Before long, if this trend continues, I may expect to be pressured to play out the third ending above. I shall be protected by the Religious Freedom Restoration Act and other guarantees of respect for "conscientious objection," but I know there are legal ways of getting rid of nurses who do not "go with the flow."

My mother recently died in a nursing home. Her heart was not good, and she had Alzheimer's. When she was forcibly immobilized after breaking her hip, she deteriorated quickly and died a week after her hip pinning. I had complete trust in her caregivers. They lovingly met her needs and endured her constant anxiety because she could not understand what was happening to her. Her family was with her when she died. That is as it should be.

I have no such confidence in the future. If my father becomes unable to care for himself in another ten years, will I have the same faith in his caregivers that I did in my mother's? I work in a nursing home. Already I regard it as a slightly dangerous place to live.

This is the much-scoffed-at "slippery slope" argument. Burke Balch, director of the medical ethics department of the National Right to Life Committee, said of a recent Appeals Court decision, "The so-called right to die will quickly become the duty to die." It is said he is "not paying attention" to the restriction that suicide assistance be granted only to those who are mentally competent and terminally ill. Appeals court Judge Stephen Reinhardt said, "The legalization of abortion has not undermined our commitment to life generally; nor, as some predicted, has it led to widespread infanticide. Similarly, there is no reason to believe that legalizing assisted suicide will lead to the horrific consequences its opponenets suggest." Even discounting the German experience, we are still left with another, more contemporary lesson in the experience of euthanasia. In the Netherlands, according to the Remmelink report (first official government study of the practice, issued in 1991), slightly more than half of all doctor-aided deaths in that country are nonvoluntary or involuntary -- without the assent of the patient or even against his will. I have yet to hear a proponent of physician-assisted suicide or voluntary euthanasia deal with that damning statistic. If this is not "reason to believe that legalizing assisted suicide will lead to ... horrific consequences," then where is evidence to the contrary?

Posted 6 Sep 2000.

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Copyright 1996 by PJ King
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