End-of-life practice in Belgium and the new euthanasia law

Validation of the Turkish adaptation of FACETS-OF-PPC: a multidimensional outcome measure for pediatric palliative care

Introduction

This study aims to validate the Turkish version of the Family-Centered Multidimensional Outcome Measure for Pediatric Palliative Care (FACETS-OF-PPC), originally developed in Germany for children with severe neurological impairments and their families.

Methods

The FACETS-OF-PPC was translated and culturally adapted following the World Health Organization's guidelines. Following expert reviews and pilot testing, the final version was completed and implemented between February and December 2021 at a pediatric palliative care center in Türkiye. Participants included family members and healthcare professionals closely involved with the patients. Exclusion criteria were age over 18, end-of-life stage, or non-Turkish speakers. Confirmatory factor analysis was conducted to evaluate the factorial validity.

Results and discussion

The study analyzed 102 responses (51 parents, 51 healthcare professionals), revealing suboptimal model fit (X2/df = 2.29; CFI=0.805; TLI=0.757; SRMR=0.109; RMSEA = 0.114). Internal consistency was adequate for the "normalcy" (w = 0.87) and "caregiver competencies" (w = 0.86) scales, but insufficient for "child's social participation" (w = 0.51), "social support" (w = 0.20), and "coping with the disease" (w = 0.50). While the Turkish version of FACETS-OF-PPC showed reliable results for certain dimensions, cultural differences and the small sample size likely affected the overall validity, suggesting the need for further refinement.

Knowledge, attitudes and practices of multiprofessional clinicians towards assisted dying in ICU: A scoping review

BACKGROUND

Care of the dying is at the forefront in intensive care unit (ICU); however there is persistent debate surrounding clinicians' interventions to aid the dying process and make this more bearable and compassionate for patients. Since the expansion of assisted dying internationally, it is unclear how common this occurs within critical care. This work aims to evaluate the knowledge, attitudes and international practices of ICU clinicians about assisted dying.

METHODS

Systematic literature search of PubMed, Embase and CINAHL including articles discussing the knowledge or attitudes towards and/or practices of assisted dying in ICU. The preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review guidelines were followed. Records were included from 2002 as the year when assisted dying was first legalised in Belgium and by healthcare professionals. A qualitative data synthesis approach was used.

RESULTS

17 studies were eligible and included in the qualitative analysis. Knowledge of assisted dying was rarely assessed directly in the data, though self-reported knowledge was low apart from in one Canadian survey of ICU physicians. Abilities to define modalities of assisted dying were low across all studies where it was measured. Attitudes were highly variable, ranging from 23.6% to 76.5% in support of assisted dying, though clinicians' answers were inconsistent within and between studies. Actual practices of assisted dying in ICU were rarely measured or discussed, despite evidence of assisted dying in Canada and The Netherlands. Outside of legal pathways, there is also evidence of covert interventions either via non-framework approaches where it is otherwise legal or in countries where there is no supportive legislation.

CONCLUSION

ICU clinicians have heterogeneous knowledge and attitudes towards assisted dying, and overall familiarity remains low. The relevance of assisted dying to the ICU setting remains controversial, and its incidence is unclear.

IMPLICATIONS FOR CLINICAL PRACTICE

Evaluating the attitudes and experiences of ICU clinicians about assisted dying is important to gain insight about clinical practices. This holistic viewpoint is key to develop management strategies focused on humanisation of care for patients and families while understanding how to support multidisciplinary clinicians in critical care so they can provide safe and respectful interventions. The identification of its incidence in legal and illegal frameworks and knowledge gaps is key when developing further research and planning tailored interventions.

What medical conditions lead to a request for euthanasia? A rapid scoping review

Background and Aims

Euthanasia is a controversial issue related to the right to die. Although euthanasia is mostly requested by terminally sick individuals, even in societies where it is legal, it is unclear what medical conditions lead to euthanasia requests. In this scoping review, we aimed to compile medical conditions for which euthanasia has been requested or performed around the world.

Methods

The review was preferred reporting items for systematic reviews and meta-analysis for scoping reviews (PRISMA-ScR) checklist. Retrieved search results were screened and unrelated documents were excluded. Data on reasons for conducting or requesting euthanasia along with the study type, setting, and publication year were extracted from documents. Human development index and euthanasia legality were also extracted. Major medical fields were used to categorize reported reasons. Group discussions were conducted if needed for this categorization. An electronic search was undertaken in MEDLINE through PubMed for published documents covering the years January 2000 to September 2022.

Results

Out of 3323 records, a total of 197 papers were included. The most common medical conditions in euthanasia requests are cancer in a terminal phase (45.4%), Alzheimer's disease and dementia (19.8%), constant unbearable physical or mental suffering (19.8%), treatment-resistant mood disorders (12.2%), and advanced cardiovascular disorders (12.2%).

Conclusion

Reasons for euthanasia are mostly linked to chronic or terminal physical conditions. Psychiatric disorders also lead to a substantial proportion of euthanasia requests. This review can help to identify the features shared by conditions that lead to performing or requesting euthanasia.

Factors affecting the attitudes and opinions of ICU physicians regarding end-of-life decisions for their patients and themselves: A survey study from Turkey

Introduction

Turkey is constitutionally secular with a Muslim majority. There is no legal basis for limiting life-support at the end-of-life (EOL) in Turkey. We aimed to investigate the opinions and attitudes of intensive care unit (ICU) physicians regarding EOL decisions, for both their patients and themselves, and to evaluate if the physicians’ demographic and professional variables predicted the attitudes of physicians toward EOL decisions.

Methods

An online survey was distributed to national critical care societies’ members. Physicians’ opinions were sought concerning legalization of EOL decisions for terminally ill patients or by patient-request regardless of prognosis. Participants physicians’ views on who should make EOL decisions and when they should occur were determined. Participants were also asked if they would prefer cardiopulmonary resuscitation (CPR) and/or intubation/mechanical ventilation (MV) personally if they had terminal cancer.

Results

A total of 613 physicians responded. Religious beliefs had no effect on the physicians’ acceptance of do-not-resuscitate (DNR) / do-not-intubate (DNI) orders for terminally ill patients, but atheism, was found to be an independent predictor of approval of DNR/DNI in cases of patient request (p<0.05). While medical experience (≥6 years in the ICU) was the independent predictor for the physicians’ approval of DNI decisions on patient demand, the volume of terminal patients in ICUs (between 10–50% per year) where they worked was an independent predictor of physicians’ approval of DNI for terminal patients. When asked to choose personal options in an EOL scenario (including full code, only DNR, only DNI, both DNR and DNI, and undecided), younger physicians (30–39 years) were more likely to prefer the "only DNR" option compared with physicians aged 40–49 years (p<0.05) for themselves and age 30–39 was an independent predictor of individual preference for "only DNR” at the hypothetical EOL. Physicians from an ICU with <10% terminally ill patients were less likely to prefer "DNR" or "DNR and DNI" options for themselves at EOL compared with physicians who worked in ICUs with a higher (>50%) terminally ill patient ratio (p<0.05).

Conclusion

Most ICU physicians did not want legalization of DNR and DNI orders, based solely on patient request. Even if EOL decision-making were legal in Turkey, this attitude may conflict with patient autonomy. The proportion of terminally ill patients in the ICU appears to affect physicians’ attitudes to EOL decisions, both for their patients and by personal preference, an association which has not been previously reported.

An Initial Investigation of Do Not Resuscitate Acceptance in Egypt

Background:

The aim of this work was to obtain objective data on the extent of knowledge and attitudes of the do not resuscitate (DNR) concept in an Egyptian urban setting.

Methods:

This survey was conducted in Cairo, Egypt, using a structured questionnaire including 23 questions. Questions and questionnaire were developed from literature on DNR in the region and from pilot testing.

Results:

A total of 461 persons participated. In all, 48 participants (10.4%, 95% confidence interval [CI]: 7.8-13.7) agreed on the concept of DNR, 226 (49%, 95% CI: 36.1-45.2) stated that it depends on the patient condition, and 187 (40.5%, 95% CI: 44.4-53.7) rejected DNR. Combining the first 2 categories, agree and depends on patient condition, over 60% of the respondents in effect supported DNR. Family members (35.6%, 95% CI: 31.4-40.3) and attending physicians (43.3%, 95% CI: 30.1-39.0) were selected over religious leaders (21%, 95% CI: 17.5-25.2) and representatives from state institutions (4.6%, 95% CI: 2.9-7.0) as to who should have authority for making a DNR decisions.

Discussion:

These and additional results provide objective evidence that DNR will not be rejected outright in Egypt. More formal surveys are justified and will provide needed guidance for implementing DNR and related end-of-life medical care in Egypt.

End-of-life decision making across cultures

Even more so than in other areas of medicine, issues at the end of life elucidate the importance of religion and culture, as well as the role of the family and other social structures, in how these issues are framed. This article presents an overview of the variation in end-of-life treatment issues across 12 highly disparate countries. It finds that many assumptions held in the western bioethics literature are not easily transferred to other cultural settings.

Compliance with DNR policy in a tertiary care center in Saudi Arabia

INTRODUCTION

Do not resuscitate (DNR) is an important aspect of medical practice, although few studies from Arab Muslim countries address this issue. King Abdulaziz Medical City (KAMC), Saudi Arabia has a policy addressing all aspects of patient care at end of life.

OBJECTIVE

To assess compliance of physicians with the current DNR policy.

METHODS

A cohort study of data prospectively collected from 15/10/2008 through 15/01/2009 for patients where DNR was initiated. Patient charts were followed prospectively to observe DNR documentation completion. Data were analyzed in terms of frequencies and descriptive statistics, and the results expressed as percentages.

RESULTS

DNR was initiated in 65 patients referred to the intensive care unit (ICU): 46.2% females, 53.8% males; age range 19-93 years, mean ± standard deviation (SD) 66.1 ± 16.0 years. DNR was initiated by ICU physician in 80% of cases and by most responsible physician (MRP) in 20% of cases. There was a delay (of more than 48 h) in completing MRP signature in 8 patients (12.3%), and no signature at all by the MRP in 13 patients (20%). Documentation of discussion with the family was absent in 53.8% of cases.

CONCLUSIONS

ICU physicians have a role in initiating DNR. Mostly this issue is not addressed on admission. Documentation of DNR once initiated is still not up to the optimum level in 32.3% of cases, mainly due to MRP. Discussion with the patient's family was not well documented in the chart in more than half of cases.

Factors related to the involvement of nurses in medical end-of-life decisions in Belgium: A death certificate study

BACKGROUND

Although nurses play an important role in end-of-life care for patients, they are not systematically involved in end-of-life decisions with a possible or certain life-shortening effect (ELDs). Until now we know little about factors relating to the involvement of nurses in these decisions.

OBJECTIVE

To explore which patient- and decision-characteristics are related to the consultation of nurses and to the administering of life-ending drugs by nurses in actual ELDs in institutions and home care, as reported by physicians.

METHOD

We sampled at random 5005 of all registered deaths in the second half of 2001--before euthanasia was legalized--in Flanders, Belgium. We mailed anonymous questionnaires to physicians who signed the death certificates and asked them to report on ELDs, including nurses' involvement.

RESULTS

Response rate was 59% (n=2950). Physicians reported nurses involved in decision making more often in institutions than at home, and more often in care homes for the elderly than in hospitals (OR 1.70, 95% CI 1.15, 2.52). This involvement was more frequently when physicians intended to hasten the patient's death than when they had no such intention (institutions: OR 2.05, 95% CI 1.41, 2.99; home: OR 2.04, 95% CI 1.19, 3.49). In institutions, this involvement was also more likely where patients were of lower rather than higher education (OR 2.95, 95% CI 1.49, 5.84). The administering of life-ending drugs by nurses, as reported by physicians was also found more frequently in institutions than at home, and in institutions more frequently with lower rather than higher educated patients (p=.037).

CONCLUSIONS

These findings raise questions about physicians' perception of the nurse's role in ELDs, but also about physicians' skills in interacting with all patients. Education and guidelines for physicians and nurses are needed to optimize good communication and to promote a clearer assignment of responsibilities concerning the execution of those decisions.