Guidelines will help end-of-life oversight

The case against Barbara Mancini (with husband Joseph) in the death of her father was thrown out by a judge.
The case against Barbara Mancini (with husband Joseph) in the death of her father was thrown out by a judge. (DAVID M WARREN / Staff Photographer)
Posted: March 06, 2014

When the hospice nurse called police in the assisted-suicide case of Barbara Mancini, David Casarett knew he had work to do.

He feared that the actions of one hospice nurse could discourage Americans from using that model of palliative care for the terminally ill, or inhibit dying people in pain from taking morphine.

So Casarett, a University of Pennsylvania physician and chief medical officer of Penn-Wissahickon Hospice, teamed with law professor Thaddeus Pope, formerly of Widener University and an expert in end-of-life law, to develop ethical guidelines for hospice workers nationwide on when to report suspicions of assisted suicide.

They have received a $50,000 grant from the Greenwall Foundation, which promotes bioethical research.

A judge threw out the case against Mancini on Feb. 11, a year after she was charged. In that time, "both her life and the lives of her family have been altered irreparably," Casarett and Pope wrote in their grant request. "Moreover, this case has a far broader societal impact. Such cases exert a dangerous chilling effect on the appropriate use of [morphine] and even on the use of hospice itself."

Mancini, 58, a Philadelphia nurse, was arrested Feb. 7, 2013, for putting morphine into the hands of her 93-year-old father. Joseph Yourshaw was terminally ill and in savage pain when, in his Pottsville home, he consumed the legally prescribed morphine she passed to him upon his request.

Barbara Cattermole, a nurse with Hospice of Central Pennsylvania, arrived soon afterward, saw Yourshaw, spoke with his daughter, and called her supervisors and police. She testified at a preliminary hearing that Mancini told her she had honored her father's wishes and attempted to help him die.

Mancini, an experienced emergency-room nurse at Lankenau Medical Center, disputed that in an Inquirer interview after the case was dismissed. She said she never tried to help him end his life, only handed him the morphine as he had asked her to do. Her father was never unconscious during the encounter, she said, adding that his living will had been trampled.

Yourshaw had repeatedly told family and hospice workers that he wanted to die and had a do-not-resuscitate order. After police were called, Yourshaw was taken by ambulance to a hospital and revived; he died there four days later, after receiving more morphine.

"The decision to throw out the case against Barbara Mancini doesn't reduce the urgency of developing hospice guidelines about assisted suicide," Casarett said this week. "It's tempting to look at this case and conclude that 'all's well that ends well,' but this experience has been very difficult for [her] and her family."

Mancini lost her job, and incurred about $100,000 in legal fees.

"Hospice staff," Casarett added, "need clear guidance about their ethical and legal obligations when they suspect that a family member has hastened a patient's death."

Reporting requirements are fraught with risk. "Anything that requires reporting, if you overdo it, there's harm," said Pope, who now teaches at Hamline University in Minnesota and publishes a blog on futility care. He will be in Philadelphia next Wednesday for a debate on end-of-life care at the World Affairs Council.

"People will err on the side of reporting," Pope said, "because they can get in trouble for not reporting."

He and Casarett said they don't blame Cattermole, the hospice nurse, who believed a crime had occurred.

In five states, consuming a lethal dose of prescribed medicine to end one's life is legal. But in Pennsylvania, it is not.

"A blanket policy that hospice staff should report any suspicion of assisted suicide would be unwise and potentially harmful," Casarett wrote in the grant proposal. "Therefore, guidance is needed regarding principles for appropriate reporting. These should balance the need to protect vulnerable patients against the need to avoid negative consequences."

The two note that more than 1.6 million people use hospice every year - a number expected to increase with growth of the elderly population and trends in increased hospice utilization.

They hope to publish their findings in prominent medical journals later this year.


mvitez@phillynews.com

215-854-5639 @michaelvitez

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