News on House Bill 140 : AN ACT TO AMEND TITLE 16 OF THE DELAWARE CODE RELATING TO END OF LIFE OPTIONS

House Bill 140 passed out of the Delaware House Human Health and Development Committee 1/19/22 and has been sent for debate in the Delaware House of Representatives. 

The boards of both the Delaware Coalition of Nurses Practitioners and the Delaware Nurses Association have voted to support this bill. 

Please take the time to review this topic and contact your legislator to state your belief.  

Here are pro and opposed opinions DCNP members shared with you previously:

Pro Argument HB 140 “Death with Dignity Act”

Suzette M. Flores, MSN, APRN, FNP-C

Palliative Care Nurse

What would constitute a good death?

What would you wish for your end-of-life care?

Many of us do not start to think about this until our later years.

What would you hope for if you were suffering near the end of your life, despite optimization of treatments?

Having worked in palliative care, end of life discussions, and end of life care planning, can be difficult and uncomfortable for patients, their families and care givers, as well as for healthcare providers with preparation, let alone without preparation.

Patients nearing the end of their life, often receive unwanted, burdensome treatments, creating increased pain, unimaginable physical suffering, and have poor quality of life towards the end of life. Loss of autonomy increases caregiver burden and stress, causing further emotional suffering to the patient. The risk versus the benefits of pursuing treatments, and the debility these treatments may cause are overlooked in conversations. Treatments may not be expressed as options, but dictated as necessary to continue one’s life, and may not be well laid out for informed decision making.

Historically, it has been a physician who has determined what end of life care should look like for a patient. In 2008, the American Public Health Association published its standpoint that terminally ill patients have the right to self-determination at the end of life to include the personal and subjective option of death based on what the terminally ill patient feels a "good death" entails (American Public Health Association, 2008).

The right to self-determination is currently expressed as cognizant decisions to forgo treatments such as not starting or stopping potentially life-sustaining therapy, palliative sedation for intractable pain, refusal of artificial nutrition and hydration via tube in the setting of poor oral intake, refusal of life saving surgery, refusal of blood products, refusal of antibiotics, refusal for initiation of or stopping of hemodialysis, and consciously or unconsciously accelerating use of or misuse of opioids to name a few. These decisions generally result in a death that would naturally occur without the intervention of modern medicine.

Death with Dignity is the underlying concept in HB140 and a right of self-determination. There are 9 United States that have legal Death with Dignity Acts, along with multiple countries and more to come.

HB 140 would allow another option in end of life care. HB 140 would permit a terminally ill patient with 6 months or less life expectancy who is an adult resident of Delaware (age 18 and above) to request and self-administer medication to end their own life in a humane and dignified manner if both the individual’s primary care physician or nurse practitioner (an option that will be added if DCNP supports this bill) and a consulting physician agree on the individual’s diagnosis and prognosis and believe the individual has decision making capacity, is making an informed decision, and is acting voluntarily.

The act allowed under HB140 is not considered suicide, assisted suicide, homicide, or euthanasia, and would offer another option in end of life care to existing comfort care, hospice care, and pain/symptom control.

HB140 has safeguards built in to protect the public when considering this as an option. Data suggests that there is little abuse. Those with progressive, incurable chronic illnesses are traditionally those who may consider this act as an option.

It would be up to the individual primary care practitioner to consider and decide how they would respond to HB140 based on legal, ethical, moral, and personal values. Even if the bill passes, primary care providers would not be required to provide this care and each practitioner’s strong personal beliefs would not be violated.

 Opposing Argument HB 140 “Death with Dignity Act”

Clare Matis, MSN, APRN-FNP-BC

Nurse Practitioner

The fundamental right of adult individuals to determine their own medical treatment options, free from coercion and in accordance with their own values, belief and personal preferences has been firmly established in our society.  For terminally ill patients, this is especially important as they may face suffering due to pain and other symptoms as well as reduction in quality of life.   Death and dying has been overmedicalized to the point where futile interventions such as artificial nutrition and hydration, artificial ventilation, and CPR are considered standards of care unless the patient specifically refuses.  To allow a natural death, in a setting of the patient’s choosing, with adequate pain and symptom management, is promoting death with dignity.  As much as House Bill 140 captures the spirit of self-determination, it is fraught with grave concerns.

First, questions are raised about the “attending physician.” There is no mention of the length or quality of relationship with the patient, the physician’s comfort level or skill set in addressing the intimate issue of death and dying, or the inclusion of nurse practitioners.  The consulting physician appears to merely confirm the patient’s diagnosis and prognosis and not address the other issues incumbent on the physician, namely, informed decision making and decisional capacity. Second, the medication to end life is not identified, nor the effect it will have on the individual before death ensues.  The consent states “most deaths occur within 3 hours, mine may take longer.”  Because the bill does not require the presence of any other individual at the time of ingestion, concerns are raised about untoward effects, such as dyspnea or seizures, that may occur which would negate the concept of “death with dignity”.  Although mental status is evaluated at the time that the request for medication is made, what if the patient decides to take that medication at a time when mental status is altered, perhaps by metabolic (hyperglycemia), pharmacologic/toxic (alcohol or substance abuse) or infectious (UTI)  aberrations that are temporary, treatable and reversible?  Also, there are no specific safeguards in place regarding keeping the lethal medication safe from diversion or misuse.  Most concerning is that the decision to hasten death is made only between a patient and physician.  A patient’s values, belief and personal preferences are a culmination of their life experience, including their individual, family and societal roles.  There is no mention in this bill of inclusion of family, spiritual or psychological counselling, nor the presence of any support,  for a competent adult at any phase of the process to end life.

Proponents of HB 140 cite a study conducted from Jan 30-Feb3 2020 where 781 Delawareans were polled; 72 percent were in support of the bill, only 50% were strongly in favor.  There are close to a million Delawareans (995, 764 to be exact) making this poll statistically insignificant.  Dr. John Goodill, Chairman of the Medical Society of Delaware Committee on Ethics, opposes the bill, confirming the American College of Physicians statements that “physician assisted suicide is neither a therapy nor a solution to the difficult questions raised at end of life… Control over the manner and timing of a person’s death has not been nor should be a goal of medicine.”  Advance health care planning, including completion of DMOST, allows patients the right to choose and direct their own health care.   With a prognosis of 6 months or less, hospice is readily available to terminally ill patients to manage physical, psychosocial and spiritual issues at end of life, with the goal of a peaceful death free from suffering.  Palliative care programs are now recognized as valuable support for patients and families at any time in the disease trajectory and certainly before the final 6 months of life.  With our health care focus and resources now rightly centered on overcoming the coronavirus pandemic, House Bill 140 should be tabled until there is further discussion on how we as nurse practitioners and physicians can address death and dying to best meet the needs of our patients within the confines of our society.