Navigating end-of-life care dilemmas: a qualitative inquiry of nurses’ and midwives’ knowledge of euthanasia and circumstantial factors influencing euthanasia in a resource-constraint setting

“Euthanasia, in simple terms, is mercy killing where you think that a patient is suffering too much and you want to end it for the patient peacefully or quietly using drugs” NM7.

“It’s all about mercy killing. The people who are suffering so much are in a lot of pain, and you, like, sometimes the pain is just too much for the patient to keep bearing for so long. That’s what you do, you give them some drugs or something to make them die to stop the suffering” NM4.

“I don’t know whether there are forms, but I know that sometimes they either inject you with something or when you are on a ventilator, they take you off. The person can state that when I get to some stage, you can kill me, or you, the person taking care of the patient, can kill the patient”. NM9.

“There can be two forms, active and passive; the active form is the one you intentionally inject the drug, and the passive one is taking a patient off a ventilation or disconnecting the patient from oxygen source.” NM11.

“the law does not support or make Euthanasia legal, neither does it even support suicide. Suppose the patient tells you to give them drugs to take under your watch once you do that. You are an ally who has attempted suicide, so you can go to jail for that. So the law criminalizes Euthanasia in this country”. NM10.

“I know that patients who are having this terminal disease that maybe they have been on life support, and then when it comes to a time, they need to take them off the life support for them to go away peacefully. This can happen in other countries but not here because it is illegal in our country” NM15.

“I cannot go begging for drugs or go taking drugs to come and give to all clients when I know that at the end of the day if the client does not pay, in my facility, it will be taken from my salary because when you are taking the drug for a patient without money, you have to write your name so if the patient does not pay You will have to pay so I cannot go taking medications for all the patients when I know I also have myself and family to feed.” MN 14.

“Sometimes you feel like helping patients, but when you consider the aftermath of you doing what is good for the patient, I quickly withdraw my thoughts. In my units, you are supposed to replace all medications used within 24 hours for others to use, and if you fail, your name is sent to the nurse manager. What follows is unpalatable, so I would rather keep their medications in the cupboard and have my peace than use it on a patient”. NM 8.

“I was once on night duty, I went to the pharmacy to take a patient’s medications because relatives were not around, and I needed to administer some. The pharmacist demanded payment for the first medications in three days before giving them to others. At this point, the patient had no medications, and we were told not to come for any medications again, so we had no choice but to leave the patient there, and in a few days, he expired. His condition was bad, so I think the family just wanted a death certificate and mortuary to keep him after death”. NM 20.

“… So, one afternoon, I went, and I could see that he had become weak and was gasping for breath. Even though the face mask was worn to give Oxygen, the saturation was not good because the cylinder was barely empty. I stood there watching, and as a junior staff, I couldn’t move on to other patients. The man was looking at me and gasping till he finally gave up. That day, I couldn’t do anything again”. NM19.

“It happens in the babies’ units often. You have delivered a baby with severe asphyxia, and this baby is not doing well; you need to give oxygen continuously and check the baby often to see if the condition is improving. If the condition is still the same, for how long are you going to give Oxygen to this child? We know how Oxygen is difficult to come by, so at times, we discontinue it to see what will happen and through this act we lose most of them or discontinue it for them to go so that we can use it for others who will survive” NM16.

“The one I witnessed was where I had my rotation some years ago, and I don’t want to mention the name. And it was a baby, a preterm baby, and a macrosomic baby, so all through, the babies were on ventilators. Then, that hospital could not keep the babies on the ventilators for long because others had to be on the ventilators, too. After all, the hospital did not have enough. They had to decide to take the babies off the ventilators, and they could not make it”. NM9.

“I witnessed one in the babies’ unit of my hospital; it happened that we had no ventilator in the NICU, so when the babies are born, and the Apgar score is bad, we are asked to keep the babies in a cot somewhere so that they can just pass on gently, it is sad but what can you do? The things are not there to work with”. NM5.

“I have observed that the moment the tag ‘palliative care’ is given to a patient, all other care ceases, right from vital signs checking to serving of medication. When you get to the patient, time is running out. Just jump to the next patient. So, there is no bed bath at times because common items for the bath are not there, and there are also not many, so nothing much is done for the patient, and he will just be lying down. We get such cases and bypass them; the sad aspect is that they eventually die”. NM15.

“There was this woman who was one of our top priority patients. We would go around her a lot of the time to assess her, but then the very time that the doctors came and wrote palliative care in her folder, the next day, I went to the older woman, and my senior colleagues whispered to me, hey, she’s on palliative care. So, that means a gradual withdrawal of care has started. I’ve seen it done to kids, older adults, and everything else. So once it is written in the patient’s document as receiving palliative care, it means we are technically going to practice euthanasia”. NM13.

“the first time I experienced the act was when we cared for a patient with colorectal cancer, and the doctors came on rounds and wrote palliative care for the patient. Subsequently, I realized that when we are on rounds and get to the patient’s bedside, we don’t attend to him. We do not do any checks, examinations, or follow-ups on him. I was off duty for two days, and when I resumed, we were told that the patient would die soon, so we should not waste our time on him. We were told to focus our attention on other patients”. NM8.

“We had a patient who was to go for prostatectomy, and the urologist called us to prepare the patient and said that he was on his way to the hospital. We sent this patient to the theatre, and the anesthetist said that the patient was gone. Can’t we see that his legs are not moving again? Meanwhile, the patient was alive, and he said we should disconnect the gadgets to save resources for other patients. Even the blood transfusion he was receiving, he commanded us to stop it. He refused to give the anesthesia, so the surgery was not done. When the Oxygen in the cylinder finished, he told us not to change the cylinder. My conscience did not allow me to do that, so I went for another one to set it up for him. I continued giving the blood, and after my off duty, I came to meet the patient alive. So, from my point of view, I think what the anesthetist was trying to do is Euthanasia, withdrawal of care”. NM15.

“The doctors prescribe expensive medications for patients to reduce the pain that was unbearable irrespective of the families’ financial status. In the case of my grandmother, who suffered cervical cancer, we were drained financially, so it got to a time we stopped buying the medications, and he died because we could not continue to buy them; we were suffering too much”. NM 17.

“There was an instance where relatives of a patient who was terminally ill on the ward for a very long time came to the ward and kept asking if we do not have anything to give to the man for him to go, especially his daughter, and at the last minute she was like as for my father he has taken a concoction and for that matter, unless we take him home he will never die here without we performing a ritual so we the health workers should aid his death for them. NM2.

“Some family members will come to dump their relatives at the hospital and go for about a month, but they will never come there to see the patients. Whether the clients are on medications or not, they do not care. They neglect him to die out of pain, hunger, loneliness, and sadness. However, you, the nurse, can only do it up to a point and leave it. You know we do not have control over the medications in the pharmacy. We sometimes buy food for them, but how long will you continue to do that? You can only do up to a point, but you can’t say you will buy all the medication for the person, so we stop at a point, and nature acts on them; that is what happens” NM 15.

“In some of the major cases we handle on the ward, a relative will come and will be like I don’t have enough money; my money is finished, so discharge the person for us to go home and sometimes, the patients also support the relatives to be allowed to go home because they can’t pay the bill. Mostly, when they say that, they write a letter to that effect, and when you refuse them, they leave the patient unattended, and as a nurse, there is little you can do so later the patient dies, and they will come, and you will direct them to the mortuary, it happens a lot, very sad”. NM23.

“I once cared for a man who was very ill, and though we didn’t do what the relative wanted us to do, they stopped buying medications because it got to a time they knew the man would not survive, and we could not use all our salaries to buy the medication continuously, so we withdrew treatment, and he finally died.” NM14.

“As for Euthanasia, it is happening on the ward. Nobody is giving anybody injections to kill anybody, but your economic situation and withdrawal of care determine your fate. NM1.

“I have witnessed a lot of indirect Euthanasia on the ward, and I saw a man with liver cancer die because he was not economically sound. In the beginning, the patient was strong and not seriously ill. He did not have insurance, and as time went on, no relative came around to pay him or purchase medications. We ceased treatment, and I said to myself, if this man were to have money, he could have been revived, and I thought we were wicked for not even giving the needed care even though he had no money”. NM19.

“I will say that it happens about 0.5% of the time, in the sense that in most of the cases I have seen, even when they do not have financial support, they beg to be treated on credit for them, but they don’t go like we don’t have money so kill the person. Mostly because they want the person to get better, they will persuade you to give care for payment later”. NM10.

“I do not think our culture encourages such practices, and you know, at times, families will go the extra mile to find money to care for their loved ones. Some people will come to the Church for financial support, and the Church will support them. Scarcely will you hear that a family has abandoned their own at the hospital.” NM22.