Introduction
Assisted dying (AD) is a controversial and complex issue, and laws governing it vary widely across different countries and regions of the world (Emanuel et al. Reference Emanuel, Onwuteaka-Philipsen and Urwin2016). The legalization of AD is expanding worldwide, leading to an increase in the number of people choosing AD. AD is either legal or in the process of being legalized in several countries, including all 6 states of Australia, parts of the United States, Austria, Belgium, Canada, Colombia, Germany, Italy, Luxembourg, the Netherlands, New Zealand, Portugal, Spain, and Switzerland (House of Commons 2024; Mroz et al. Reference Mroz, Dierickx and Deliens2021). AD raises important questions about individual autonomy, medical ethics, and the role of government in regulating end-of-life care (Dugdale et al. Reference Dugdale, Lerner and Callahan2019; Fontalis et al. Reference Fontalis, Prousali and Kulkarni2018; Snyder Sulmasy and Mueller Reference Snyder Sulmasy and Mueller2017). Attitudes toward the topic vary and are related to aspects like moral attitudes and individual experiences (Kletecka-Pulker et al. Reference Kletecka-Pulker, Völkl-Kernstock and Atanasov2022).
Assisted suicide (AS) typically refers to a situation where an individual takes the final action to end their life without the assistance of another person. AD, on the other hand, is a broader term that encompasses different practices and legal frameworks related to end-of-life decisions. It can include both AS and other forms of AD, such as euthanasia. Euthanasia involves the direct administration of a lethal dose of medication by another person to end the life of a patient at their request. In Austria, the regulations on AS are specific and limited to persons with a serious, incurable illness.
Palliative care (PC) is an approach that aims to improve the quality of life of patients facing serious illness, regardless of their prognosis. It focuses on symptom management and addresses the psychological, social, and spiritual needs of patients and their families. PC can be provided at any stage of the illness, from diagnosis onward, and in a variety of settings, including hospitals, outpatient clinics, and even the home. Hospice care, on the other hand, is specifically designed for people nearing the end of life. In Austria, it is usually provided in a special hospice facility. Hospice care focuses on providing comfort and support to patients in their final weeks and months.
The Austrian government agreed on a new legal regulation of AS in January 2022. AS is regulated by the recently adopted federal Assisted Dying Act (Sterbeverfügungsgesetz, StVfG), which allows seriously ill people access to medical AS if they have an incurable disease leading to death, or live with a serious, permanent illness with persistent symptoms that permanently impair their entire way of life. Minors are not eligible.
The Assisted Dying Act in Austria entitles authorized persons willing to die to establish a dying will and get access to a lethal preparation of phenobarbital. The process involves consulting with 2 physicians, one of whom must have a qualification in PC (Khakzadeh Reference Khakzadeh2022; Kitta et al. Reference Kitta, Ecker and Zeilinger2023). The 2 physicians are responsible for verifying the person’s voluntary decision, discussing other alternatives, and determining the appropriate dosage of the lethal medication. If there are indications of mental impairment, a psychiatrist or clinical psychologist must also be consulted. Within the description of the official process in the legislation, nurses are not mentioned to be involved.
The role of nurses in delivering comprehensive care to persons with life-limiting illnesses is essential. However, research on nurses’ attitudes toward AS is scarce (Pesut et al. Reference Pesut, Greig and Thorne2020). Nurses caring for terminally ill patients are frequently confronted with patients expressing wishes to die (Richardson Reference Richardson2023), but communication with patients about AS can be a difficult and sensitive subject for nurses (Sandham et al. Reference Sandham, Carey and Hedgecock2022). When patients ask for aid in the dying process, nurses may encounter inner moral turmoil and a sense of helplessness (Cayetano-Penman et al. Reference Cayetano-Penman, Malik and Whittall2021). The topic of AS can pose ethical dilemmas for nurses, as it may conflict with their personal or professional beliefs, leaving them uncertain about their participation in the process or causing emotional distress (Woods and Rook Reference Woods and Rook2022). They may feel torn between their duty to provide compassionate care and their obligation to follow legal and ethical guidelines. To navigate these considerable ethical and emotional burden on nurses, it is important to investigate the experience of nurses during this special time after the implementation of the new law on AS.
The main aim of the present study was to assess the experiences and attitudes of palliative and hospice care nurses toward AS and the new legislation in Austria 1 year after its implementation. In addition, we aimed to identify factors influencing nurses’ attitudes toward AD. The following research questions were addressed, all relating to the period after the first year of implementation of the new legislation: (1) How many nurses have been confronted with patients requesting or actually undergoing AS? (2) What are nurses’ attitudes toward AS? (3) How comfortable are nurses in discussing AS? (4) What factors influence nurses’ attitudes toward AS?
Methods
The study was a cross-sectional, observational survey study. We followed the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE; Elm et al. Reference Elm, Altman and Egger2007) guidelines.
Materials
A German-language questionnaire was designed based on published and validated instruments (Ganzini et al. Reference Ganzini, Harvath and Jackson2002; Miller et al. Reference Miller, Harvath and Ganzini2004). It consisted of the following sections: demographic information, attitudes and beliefs, recent experiences with wishes for AS, and received support and support needs (see Supplementary Material).
We included 1 item on general attitudes toward legalizing AS, and explored this aspect in more depth using the 4-Item Assisted Suicide Attitude Scale (ASAS), and the 5-Item Comfort Discussing Assisted Suicide Scale (CDASS) (Miller et al. Reference Miller, Harvath and Ganzini2004). The items in both scales are rated on a 5-point Likert scale ranging from 1 to 5. Higher total scores on each scale indicate more positive attitudes toward AS and more comfort discussing AS. For both scales, a score was calculated for each respondent using the average of items. Scores were only calculated if at least 3 items were answered in the respective scale. Otherwise, a missing value was assigned to the respondent (n = 38 for the ASAS and n = 29 for the CDASS). Cronbach’s alpha for the ASAS was α = .86 and for the CDASS α = .89.
Translation of English-language content was conducted using the parallel-blind method (Behling and Law Reference Behling and Law2000). Two people independently translated the questions and established a final version with the help of a third person. In addition, a bilingual person whose native language is English reviewed the final version. The questionnaire was piloted in a sample of volunteers, comprising nurses, PC physicians, psychologists, and psychometric specialists. Comments of the pilot phase were implemented to refine and optimize the questionnaire. The final questionnaire took about 15–20 minutes to complete.
Procedure
The questionnaire was distributed online. A link to the questionnaire was sent to all specialized and general hospice and PC facilities with practicing nurses throughout all 9 states of Austria via email. This included n = 255 facilities. One initial email and one reminder email were sent to all relevant facilities. This sampling strategy was complemented by a snowballing technique. Nurses who received the link were asked to forward it to other nurses in the field of palliative or hospice care. Snowballing generally improves participant recruitment, and positively affects the diversity of the sample (Rowe and Wright Reference Rowe and Wright2011). The questionnaire could be completed from end of September to end of December, 2022, at the end of the first year when AS was legalized in Austria.
The following inclusion criteria were applied: (1) being a palliative or hospice care nurse in Austria, (2) at least 18 years of age, (3) sufficient German language skills to complete the questionnaire. After receiving study information, participants gave their informed consent on the first page of the questionnaire by agreeing to a consent form with a click on a button. Responses to the questionnaire were fully anonymous. This also implied that we had no control to ensure that a person did not complete the questionnaire more than once. Ethical approval was obtained from the institutional ethics committee of the Medical University of Vienna (No. 1373/2022).
Statistical methods
Spearman’s correlation coefficient was computed for determining bivariate associations between sociodemographic characteristics and attitudes toward AS, as well as comfort discussing AS. For comparison of frequencies, we applied ꭓ2 tests. We computed a linear regression model to examine predictors for attitudes toward AS, assessed by the ASAS. The following independent variables were entered: age in years, working experience in years, gender (male/female), educational level (4 categories addressing general education, not including further specializations), religiousness (5 categories), and experience with patients expressing a wish for AS (yes/no). Variance inflation factors indicated no multicollinearity between variables.
We used an alpha level of 5% for determining statistical significance. Additionally, we interpreted effect sizes following Cohen’s guidelines (Cohen Reference Cohen1988).
Results
Sample
The final sample comprised 280 nurses (82.9% female). Mean age was 45.94 years (SD = 9.88). The median experience of working in a hospice or PC setting was 10 years. A total of 31 nurses (11.1%) reported that their employer allowed AS within the organization, while 166 (59.3%) reported that the employer prohibited it. Nearly one quarter of the sample (n = 67) stated that they did not know about any regulation in their organization or that it was not clear, yet. Sample characteristics are depicted in Table 1.
Sample characteristics
Experiences
In the total sample, 61.2% of nurses indicated that at least 1 of their patients had expressed the wish for AS. Given numbers ranged from 1 patient to 20 patients (Mdn = 2). Of all nurses, 22.7% indicated that at least 1 of their patients had a dying will legally approved. The range of numbers was 1 patient to 10 patients, with a median of 2 patients. A total of 16.2% of nurses reported that at least 1 patient had carried out an AS. This included 37 nurses who reported that 1 of their patients had completed an AS and 8 nurses who reported that 2 of their patients had completed an AS. It should be noted that this number does not reflect the number of individual patients who have completed AS. As a patient is usually cared for by several nurses, these experiences may partly relate to the same patients.
Attitudes
Nurses’ general attitudes, as assessed by a single question asking directly about their attitudes on AS, varied widely across the sample. More nurses expressed a supportive attitude (49.28%) compared to those who were opposed to legalization (31.07%, see Figure 1). On the 4-item ASAS, the mean value for the total sample was 3.23 (SD = 1.13), which resembles a slightly positive attitude. The results on the 4 individual items of the ASAS for the total sample are depicted in Figure 2. As expected, there was a strong association between the general attitude items and the ASAS score, with r sp = .75, p < .001, supporting the validity of the ASAS.
General attitudes of nurses toward legalization of assisted suicide.
Assisted suicide attitudes scale.
We observed a small, but statistically significant association between attitudes toward AS, as assessed by the ASAS, and age (r sp = −.19, p = .003), with younger nurses reporting more positive attitudes toward AS. More positive attitudes toward AS were also expressed by nurses who were less religious (r sp = −.31, p < .001). There was no significant association between attitudes toward AS and length of working experience in PC (r sp = −.07, p = .273), nor with level of education (r sp = −.05, p = .398).
The vast majority of nurses (75.5%) reported that their attitudes had not changed during the first year of legalization in Austria. A total of 20.5% reported that their attitudes had changed a little, and 4% reported that their attitudes had changed a lot in this first year.
Comfort discussing AS
On the CDASS, the mean value for the total sample was 3.87 (SD = .96). There was no association with age (r sp = .07, p = .296), with length of experience working in PC (r sp = −.04, p = .569), nor with educational level (r sp = .04, p = .558). There was a small statistically significant negative association with religiousness (r sp = −.135, p = .033). Frequencies of the 5 individual items on the CDASS are depicted in Figure 3. The highest level of comfort with discussing AS was observed when discussing it with a colleague or supervisor in a case-based professional manner. The comfort level of discussing AS with patients was significantly lower than that of discussing it with colleagues or a supervisor (p s < .001).
Level of comfort discussing assisted suicide.
Determinants of attitudes toward AS
A regression analysis was conducted to examine relevant determinants of attitudes toward AS. The dependent variable was the ASAS score. The overall regression model was significant (p < .001) with R 2 = .16. Results indicate, that religiousness, age, and experience with patients expressing a wish for AS had a significant impact on attitudes toward AS. The most important factor was religiousness, with less religious nurses reporting more positive attitudes toward AS. Younger nurses also had more positive attitudes. Interestingly, nurses who reported having cared for a patient with an AS request had less positive attitudes toward AS (see Table 2).
Regression model for attitudes toward assisted suicide
The dependent variable was the ASAS score, with higher values representing more positive attitude toward assisted suicide.
a 0 = male, 1 = female.
b 0 = no, 1 = yes.
Discussion
The findings of this study, conducted at the end of the first year following the legalization of AS in Austria, show that a notable proportion of nurses, almost a quarter, expressed a lack of knowledge or uncertainty about their employer’s position on the matter. The analysis revealed that religiousness, age, and experience with AS-interested patients significantly affected nurses’ attitudes toward AS, with religiousness being the most influential. The results align with prior research, stating that individuals with stronger religious beliefs are more likely to express objections to AS (Balslev van Randwijk et al. Reference Balslev van Randwijk, Opsahl and Assing Hvidt2020; Evenblij et al. Reference Evenblij, Pasman and van der Heide2019; Sabriseilabi and Williams Reference Sabriseilabi and Williams2022). Thus, it becomes crucial to comprehend how personal values, including religious convictions, can shape the attitudes toward various aspects of clinical decision-making. In this study, attitudes toward AS exhibited variation, with 49% of nurses expressing support for AS, while 31% were opposed to AS.
The growing acceptance of AS can be interpreted as a consequential societal transformation, with the legalization of such practices being accompanied by a subsequent shift in societal attitudes (Cayetano-Penman et al. Reference Cayetano-Penman, Malik and Whittall2021). This trend is exemplified by international patterns observed across different countries (Attell Reference Attell2020; Kresin et al. Reference Kresin, Hawgood and De Leo2021; Montagna et al. Reference Montagna, Junker and Elfgen2023; Mroz et al. Reference Mroz, Dierickx and Deliens2021). Similarly, the present study reflected findings that younger workers exhibited more positive attitudes with AS (Piili et al. Reference Piili, Louhiala and Vänskä2022).
Nurses who reported having provided care to a patient with a request for AS displayed less positive attitudes toward AS. This may be due to the fact that excessive demands arose as a result of the new legislation, or that AS is in conflict with the efforts of end-of-life caregivers to achieve the best possible symptom relief (Piili et al. Reference Piili, Louhiala and Vänskä2022; Richardson Reference Richardson2023; Sellars et al. Reference Sellars, Tacey and McDougall2021; Zeilinger et al. Reference Zeilinger, Gabal and Adamidis2022). Length of work experience or level of education did not demonstrate a significant impact on attitudes toward AS.
The highest degree of comfort in engaging in discussions about AS was observed when conversing with a colleague or supervisor in a professional context, whereas it was notably lower when discussing with patients. Given the inevitable involvement of nurses in regard to AS, it is imperative to recognize the necessity for comprehensive education and information regarding the management of patients expressing a desire to hasten death, as well as a deep understanding of the legal aspects surrounding AS (Cayetano-Penman et al. Reference Cayetano-Penman, Malik and Whittall2021; Willmott et al. Reference Willmott, White and Ko2020; Yoong et al. Reference Yoong, Wang and Seah2023). Such information provision seems to be crucial in equipping nurses with the necessary skills and knowledge to navigate these complex situations effectively (Sellars et al. Reference Sellars, Tacey and McDougall2021).
Limitations of the study include that the survey was conducted during a single data collection period due to the timeliness of the recent legalization of AS in Austria, lacking a longitudinal follow-up and the ability to track changes in attitudes over time. Moreover, the representativeness of the findings may be compromised due to the voluntary nature of participation in the survey. Due to the full anonymity of data collection, we had no control to ensure that a person did not complete the questionnaire more than once. However, we consider this unlikely as we would not expect nurses to use their time to complete the same questionnaire more than once. We are also unable to give a response rate due to the nature of the data collection, which involved facilities distributing the questionnaire to their nurses, and the snowball sampling technique. The strengths of the study include that the survey was administered promptly after the introduction of the new legislation, providing valuable, novel insights into the challenges that nursing staff may encounter with the new system. Additionally, the survey took place in the field of hospice and PC, where a differentiated discussion of end-of-life issues is to be expected. Thus, a realistic picture of the opinion of those nurses who care for seriously ill people can be assumed.
Conclusions
AS is a subject of significant sensitivity and controversy, necessitating a thorough societal discourse. The establishment of a legal framework that upholds individual rights and values, coupled with the implementation of robust safeguards, is paramount to mitigating the risk of abuse. It is important to recognize that perspectives on this issue vary considerably and are influenced by a range of ethical, religious, cultural, and personal beliefs. The results of this study provide insights into the challenges that the new legislation may pose for nurses and may therefore contribute to a more informed discussion about AS.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S147895152400107X.
Data availability statement
The data that support the findings of this study are available from the corresponding author, ELZ, upon reasonable request.
Author contributions
ELZ and MU were co-chief investigators of this study. EKM and AP contributed to study design. NB contributed to project management and designing the online questionnaire. All authors contributed to the conception of the study and data collection. ELZ, AF, and JP analyzed the data. ELZ and AF designed the figures. ELZ and EKM wrote the first draft of this manuscript. All authors contributed to and approved the final manuscript.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Competing interests
The authors have no relevant financial or non-financial interests to disclose.
Ethical approval
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration. Ethical approval was obtained from the institutional ethics committee of the Medical University of Vienna, Austria (No. 1373/2022).
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