20% of ICU Nurses Have Aided Deaths, Survey Finds

A controversial survey of nurses in hospital intensive care units finds that nearly one out of five have hastened the death of critically ill patients at least once in their careers, occasionally without explicit permission from patients, doctors or family members.

The results, some experts suggest, add to the heated national controversy over ending the life of terminally ill people who are subjected to heroic medical measures that can’t possibly rescue them.

Of 852 respondents to an anonymous mail survey, 16% said they had performed euthanasia or assisted in a suicide at the request of patients or doctors, while another 4% said they had done so without being asked and sometimes even contrary to doctors’ orders.

Those figures may seem frighteningly high, but the nurses surveyed had been in the profession for an average of nine years and had treated 1,000 or more patients a year, said the study’s author, Dr. David Asch of the University of Pennsylvania. So while a significant number of nurses recalled engaging in the practice at least once, he explained, the practice involved only a tiny fraction of patients in intensive care.

“I don’t think there’s anything in this survey that should make people afraid of being in the hospital,” said Dr. William Knaus, ICU director at the University of Virginia and a noted authority on end-of-life care.

“I think the study shows that there is an underground, unregulated practice of hastening death in this country,” said nurse Constance Holden, a hospice director in Boulder, Colo., and a board member of Death With Dignity, a group that advocates legalizing assisted suicide.

The American Nursing Assn. and the American Assn. of Critical-Care Nurses condemned the study, which appears today in the New England Journal of Medicine. “Nurses do not kill the patients entrusted to their care,” the groups said in a combined statement, adding that the study was “erroneous” and “not to be relied on.”

The nursing groups, which represent more than 2 million professionals, have issued guidelines prohibiting assisted suicide and euthanasia.

But Jerald Bachman, a social psychologist specializing in survey methods at the University of Michigan who has studied physician attitudes toward assisted suicide, said the overall study design was reasonable, especially given the large number of respondents. “It doesn’t seem to be overly biased one way or another,” he said when told of the survey methods.

Asch responded to the critics by saying that the key result is not the precise number of nurses who have participated in such practices. “The important finding is that the number is not zero,” he said.

Asch mailed the eight-page survey to 1,600 ICU nurses who subscribed to Nursing magazine. Of the 1,139 who responded, the survey compiled statistics from 852 because they were full-time adult ICU nurses. The relatively high response level, Bachman said, shores up the findings.

The survey did not count the withdrawal of feeding or breathing tubes from a patient as an act of euthanasia or assisted suicide, chiefly because such practices are considered ethical and legal in some circumstances, Asch explained.

The most common method of hastening death reported by the nurses was administering a high dose of morphine.

But that itself raises a question about the study, said Collee Scanlon, a nurse and lawyer at the American Nurses Assn. It is widely accepted practice within hospices to administer high doses of painkillers to a terminally ill person in pain, knowing that the drug might hasten death by gradually depressing respiration.

Ethicists refer to that as the principle of double effect, and even groups that oppose euthanasia sometimes accept it because the primary intention is to ease pain, not cause death.

But some nurses in the Asch study who administered medication with that intention could have been lumped in with those who deliberately committed euthanasia by overdosing the patient, Scanlon said. That would inflate the number of nurses engaging in that outlaw practice, invalidating the study, she said. Because of the study, she said she fears that gravely ill patients will stay away from care directed at easing pain.

But Asch said, “I do not believe the results of the study suggest that patients or the public should fear or distrust critical care nurses. . . . These nurses struggle to uphold important personal values under extremely challenging circumstances.”

Much recent research has focused on physician attitudes and practices, so this study fills a long-overlooked gap, Knaus said, adding: “Nurses spend more time at the bedside facing these problems than anyone else in health care.”