[Guide document for assistance the end of the life]

There are not any laws in Italy that rule the path of the end of life. Therefore, the doctor has to take as a reference the Supreme Judgment of the Court of Cassation 16/10/2007 n 21748. The author is proposing a different, realistic and convenient form that could be used by the patient and both his tutor and doctor to walk through the path that brings to the end of life. This document shows respect for the sanctity of life and safeguards willingness and dignity of the patient. Its purpose is to register the treatment for symptoms that leads to death, basing the relationship between a patient and his doctor on trust and confidence.

[Anticipating the end of life, planning for the loss of intellectual autonomy]

More than ten years after the Leonetti law was passed, the French parliament has definitively adopted legislation granting new rights to people at the end of life. This new legislation is the result of persistent public pressure. French people want to see their wishes respected with regard to their end-of-life care. How and in what conditions should such measures be applied in the case of patients at the end of life and with diminished intellectual autonomy?

Caring for the dying in a developing country, how prepared are we?

End of life care is framework to allow for a peaceful, comfortable and dignified death while considering the patients' personal and religious values, bioethics and knowledge of the disease process. A well planned end of life pathway should allow for the flexibility to shift from an active (or aggressive) treatment approach to one of comfort and care when initial interventions have failed. The need for this pathway is most apparent in the intensive care setting. Implementation of a pathway will face various challenges due to religious and cultural beliefs, education of healthcare providers to carry out difficult discussions and larger socioeconomic implications. Clear medico-legal framework will be required to support this pathway. In conclusion, an end of life pathway tailored to our local needs is the way forward in allowing for dignified death of terminally ill patients; this will require the active participation of medical societies, religious leaders, healthcare providers, patients and their care givers.

Medical murder in Belgium and the Netherlands

This article is a response to Raphael Cohen-Almagor's paper entitled 'First do no harm: intentionally shortening lives of patients without their explicit request in Belgium'. His paper deals with very important matters of life and death, however its concept usage is in part misleading. For instance, the fact that medical murder takes place both in Belgium and the Netherlands is missed. Cohen-Almagor calls such acts 'worrying' and considers them to be 'abuse'. However, it remains an open question whether or not there can be such a thing as legitimate murder in a medical context. From the combined perspectives of justice and the duty to end unbearable suffering, there might be. Thus, key arguments for euthanasia are also prominent in an argument for medical murder.

Continuous deep sedation and homicide: an unsolved problem in law and professional morality

When a severely suffering dying patient is deeply sedated, and this sedated condition is meant to continue until his death, the doctor involved often decides to abstain from artificially administering fluids. For this dual procedure almost all guidelines require that the patient should not have a life expectancy beyond a stipulated maximum of days (4-14). The reason obviously is that in case of a longer life-expectancy the patient may die from dehydration rather than from his lethal illness. But no guideline tells us how we should describe the dual procedure in case of a longer life-expectancy. Many arguments have been advanced why we should not consider it to be a form of homicide, that is, ending the life of the patient (with or without his request). I argue that none of these arguments, taken separately or jointly, is persuasive. When a commission, even one that is not itself life-shortening, foreseeably renders a person unable to undo the life-shortening effects of another, simultaneous omission, the commission and the omission together should be acknowledged to kill her. I discuss the legal and ethical implications of this conclusion.

Why I wrote my advance decision to refuse life-prolonging treatment: and why the law on sanctity of life remains problematic

This paper, pursuing themes indefatigably defended in this journal and elsewhere by Professors Jenny and Celia Kitzinger, explains what led me to write my own advance decision (AD) to refuse life-prolonging treatment if I become legally incapacitated to make my own healthcare decisions for longer than 3 months and am medically assessed as very unlikely to regain such legal capacity. I attach my Advance Decision to Refuse Life Prolonging Treatment to the online version of this paper for comment advice and possible general interest. I argue that while a Supreme Court judgement in 2013, followed by a Court of Protection judgement in 2015 greatly ameliorate my earlier concerns about excessive judicial emphasis on the sanctity of life, certain current requirements in the Code of Practice to the Mental Capacity Act 2005 and in the Rules of the Court of Protection, especially Practice Direction 9E, concerning permanent vegetative state and minimally conscious state, seem clearly to contradict aspects of that Supreme Court judgement. If the logical implications of those legal requirements were thoroughly implemented medical practice would be substantially and undesirably skewed towards provision of treatments to prolong life that are unwanted, non-beneficial and wasteful of healthcare resources. I urge that these legal requirements are modified to make them consistent with the Supreme Court's judgement in Aintree v James.

Knowledge of the law about withholding or withdrawing life-sustaining treatment by intensivists and other specialists

OBJECTIVE

Decisions about withholding or withdrawing life-sustaining treatment (WWLST) from adults who lack capacity are an integral part of intensive care (IC) practice. We compare the knowledge, attitudes and practice of intensivists in relation to the law about WWLST with six other specialties most often involved in end-of-life care.

DESIGN, SETTING AND PARTICIPANTS

We used a cross-sectional postal survey of medical specialists in the three most populous Australian states, and analysed responses from 867 medical specialists from the seven specialties most likely to be involved in WWLST decisions in the acute-care setting (emergency, geriatric, palliative, renal and respiratory medicine, medical oncology and IC).

MAIN OUTCOME MEASURES

Attitudes to, and knowledge and practice of, the law relating to end-of-life care.

RESULTS

Of 2702 surveys sent to eligible practitioners, 867 completed questionnaires were returned. There was an overall response rate of 32% and an IC response rate also of 32% (125/388). Intensivists performed better than average in legal knowledge but important knowledge gaps remain. Intensivists had a more negative attitude to the role of law in this area than other specialty groups but reported being seen as a leading source of information about legal issues by other medical specialists and nurses. Intensivists also reported being the specialists most frequently making decisions about end-of-life treatment.

CONCLUSIONS

Improved legal knowledge and open engagement with the law can help manage the risk of harm to patients and protect intensivists from liability. IC guidelines and continuing professional development are important strategies to address these issues.

Legal Standards for Brain Death and Undue Influence in Euthanasia Laws

A major appellate court decision from the United States seriously questions the legal sufficiency of prevailing medical criteria for the determination of death by neurological criteria. There may be a mismatch between legal and medical standards for brain death, requiring the amendment of either or both. In South Australia, a Bill seeks to establish a legal right for a defined category of persons suffering unbearably to request voluntary euthanasia. However, an essential criterion of a voluntary decision is that it is not tainted by undue influence, and this Bill falls short of providing adequate guidance to assess for undue influence.

Too ill to will? Deathbed wills: assessing testamentary capacity near the end of life

Assessing testamentary capacity in the terminal phase of an illness or at a person's deathbed is fraught with challenges for both doctors and lawyers. Numerous issues need to be considered when assessing capacity for a will. These issues are exacerbated when such an assessment needs to be undertaken at the bedside of a dying patient. The nature and severity of the illness, effects on cognition of the terminal illness, effects of medication, urgency, psychological and emotional factors, interactions with carers, family and lawyers, and a range of other issues confound and complicate the assessment of capacity. What is the doctor's role in properly assessing capacity in this context and how does this role intersect with the legal issues? Doctors will play an increasing role in assessing testamentary capacity in this setting. The ageing of society, more effective treatment of acute illness and, often, the prolongation of dying are only some of the factors leading to this increasing need. However, despite its importance and increasing prevalence, the literature addressing this challenging practical area is scarce and offers limited guidance. This paper examines these challenges and discusses some practical approaches.

Advanced Directives and Advanced Care Planning for Healthcare Professionals

The purposes of this study were to assess healthcare professionals' need for information on advanced directives and to implement and evaluate an educational plan for change in knowledge and behaviors related to advanced directives. End-of-life (EOL) care is an important topic for patients to discuss with their families and healthcare professionals (HP). Needs assessment data were collected from healthcare providers at an urban trauma intensive care unit (ICU) in Louisville, Kentucky on concepts related to end-of-life. Next, healthcare professionals participated in an educational intervention focused on: knowledge about advanced directives; communication techniques for healthcare professionals to use with patients and their families; awareness of the patient's level of illness in advanced care planning; and specifics about living wills in Kentucky and how to complete one. Pre- and post-test data were collected to evaluate change in knowledge, capability an average of 8.7 years (SD = 9.1; range = 1.9-35 years) in healthcare and worked an average of 8.4 years (SD = 9.3; range = 4 months to 35 years) in their respective ICUs. Eighty-seven percent did not have an AD in place even though their perceived knowledge about AD remained moderate throughout pre- and post-test scores (3.3 to 3.8 on a 5 point scale, respectively). Total post-test scores revealed a 2% improvement in correct responses. These findings point to the need for education of healthcare providers in the ICU to increase early AD and ACP discussions with patients and their families.

The impact of the Rasouli decision: a Survey of Canadian intensivists

INTRODUCTION

In a landmark 2013 decision, the Supreme Court of Canada (SCC) ruled that the withdrawal of life support in certain circumstances is a treatment requiring patient or substitute decision maker (SDM) consent. How intensive care unit (ICU) physicians perceive this ruling is unknown.

OBJECTIVES

To determine physician knowledge of and attitudes towards the SCC decision, as well as the self-reported changes in practice attributed to the decision.

METHODS

We surveyed intensivists at university hospitals across Canada. We used a knowledge test and Likert-scale questions to measure respondent knowledge of and attitudes towards the ruling. We used vignettes to assess decision making in cases of intractable physician-SDM conflict over the management of patients with very poor prognoses. We compared management choices pre-SCC decision versus post-SCC decision versus the subjective, respondent-defined most appropriate choice. Responses were compared across predefined subgroups. We performed qualitative analysis on free-text responses.

RESULTS

We received 82 responses (response rate=42%). Respondents reported providing high levels of self-defined inappropriate treatment. Although most respondents reported no change in practice, there was a significant overall shift towards higher intensity and less subjectively appropriate management after the SCC decision. Attitudes to the SCC decision and approaches to disputes over end-of-life (EoL) care in the ICU were highly variable. There were no significant differences among predefined subgroups.

CONCLUSIONS

Many Canadian ICU physicians report providing a higher intensity of treatment, and less subjectively appropriate treatment, in situations of dispute over EoL care after the Supreme Court of Canada's ruling in Cuthbertson versus Rasouli.

Religious, Ethical and Legal Considerations in End-of-Life Issues: Fundamental Requisites for Medical Decision Making

Religion and spirituality have always played a major and intervening role in a person's life and health matters. With the influential development of patient autonomy and the right to self-determination, a patient's religious affiliation constitutes a key component in medical decision making. This is particularly pertinent in issues involving end-of-life decisions such as withdrawing and withholding treatment, medical futility, nutritional feeding and do-not-resuscitate orders. These issues affect not only the patient's values and beliefs, but also the family unit and members of the medical profession. The law also plays an intervening role in resolving conflicts between the sanctity of life and quality of life that are very much pronounced in this aspect of healthcare. Thus, the medical profession in dealing with the inherent ethical and legal dilemmas needs to be sensitive not only to patients' varying religious beliefs and cultural values, but also to the developing legal and ethical standards as well. There is a need for the medical profession to be guided on the ethical obligations, legal demands and religious expectations prior to handling difficult end-of-life decisions. The development of comprehensive ethical codes in congruence with developing legal standards may offer clear guidance to the medical profession in making sound medical decisions.

The Carriage of Death: What Kind Does Canada Have?

Using a carriage of death metaphor, based on Emily Dickinson's poem "Because I Could Not Stop for Death", the authors highlight the development of the last 40 years of the Canadian legal landscape and end-of-life decision making. Beginning with the Canadian Criminal Code, moving through the Rodriguez decision and ending with the recent 2015 Carter decision, they explore how the evolution of time has influenced Canada's highest court. The authors conclude with an exploration of advance care directives and what we may expect as Canada continues its travels down this road.