Intentionally hastening death by withholding or withdrawing treatment

Could palliative sedation be seen as unnamed euthanasia?: a survey among healthcare professionals in oncology

BACKGROUND

In 2016 a French law created a new right for end-of-life patients: deep and continuous sedation maintained until death, with discontinuation of all treatments sustaining life such as artificial nutrition and hydration. It was totally unprecedented that nutrition and hydration were explicitly defined in France as sustaining life treatments, and remains a specificity of this law. End- of-life practices raise ethical and practical issues, especially in Europe actually. We aimed to know how oncology professionals deal with the law, their opinion and experience and their perception.

METHODS

Online mono-centric survey with closed-ended and open-ended questions in a Cancer Comprehensive Centre was elaborated. It was built during workshops of the ethics committee of the Institute, whose president is an oncologist with a doctoral degree in medical ethics. 58 oncologists and 121 nurses-all professionals of oncological departments -, received it, three times, as mail, with an information letter.

RESULTS

63/ 179 professionals answered the questionnaire (35%). Conducting end-of-life discussions and advanced care planning were reported by 46/63 professionals. In the last three months, 18 doctors and 7 nurses faced a request for a deep and continuous sedation maintained until death, in response to physical or existential refractory suffering. Artificial nutrition and even more hydration were not uniformly considered as treatment. Evaluation of the prognosis, crucial to decide a deep and continuous sedation maintained until death, appears to be very difficult and various, between hours and few weeks. Half of respondents were concerned that this practice could lead to or hide euthanasia practices, whereas for the other half, this new law formalised practices necessary for the quality of palliative care at the end-of-life.

CONCLUSION

Most respondents support the implementation of deep and continuous sedation maintained until death in routine end-of-life care. Nevertheless, difficulty to stop hydration, confusion with euthanasia practices, ethical debates it provokes and the risk of misunderstanding within teams and with families are significant. This is certainly shared by other teams. This could lead to a multi-centric survey and if confirmed might be reported to the legislator.

Overcoming Conflicting Definitions of "Euthanasia," and of "Assisted Suicide," Through a Value-Neutral Taxonomy of "End-Of-Life Practices"

The term "euthanasia" is used in conflicting ways in the bioethical literature, as is the term "assisted suicide," resulting in definitional confusion, ambiguities, and biases which are counterproductive to ethical and legal discourse. I aim to rectify this problem in two parts. Firstly, I explore a range of conflicting definitions and identify six disputed definitional factors, based on distinctions between (1) killing versus letting die, (2) fully intended versus partially intended versus merely foreseen deaths, (3) voluntary versus nonvoluntary versus involuntary decisions, (4) terminally ill versus non-terminally ill patients, (5) patients who are fully conscious versus those in permanent comas or persistent vegetative states, and (6) patients who are suffering versus those who are not. Secondly, I distil these factors into six "building blocks" and combine them to develop an unambiguous, value-neutral taxonomy of "end-of-life practices." I hope that this taxonomy provides much-needed clarification and a solid foundation for future ethical and legal discourse.

Getting Real About Killing and Allowing to Die: A Critical Discussion of the Literature

The moral significance of the distinction between killing and allowing to die has played a key role in debates about euthanasia and physician assisted suicide. Since the withdrawal of life-sustaining treatment is held as morally permissible in the medical community, it follows that if there is no morally significant difference between killing and allowing to die, then there is no morally significant difference between withdrawing life-sustaining treatment or administering a lethal injection to end a patient’s life. Consistency then requires that voluntary active euthanasia (VAE) is also morally permissible. The debates over whether the distinction is morally significant have carried on for decades with little hope of consensus. We begin by surveying the literature to identify common argumentative strategies used in defending or rejecting the distinction’s significance. We observe, based on our review, that many of these strategies operate in ways that are conceptually removed from the concrete clinical situation of physicians involved in practices that lead to patient death (by withdrawal of treatment or VAE). We conclude by arguing for a novel way of moving the debate forward indicated by our reading of the literature, namely, by paying careful attention to the moral experience of physicians involved in end-of-life interventions to understand how they experience these practices. Exploring physician experience can reveal how the distinction may or may not be useful for moral deliberation and can provide the needed context to theorize about the distinction in a more empirically informed and practically useful way.

Hastening Death in Canadian ICUs: End-of-Life Care in the Era of Medical Assistance in Dying

OBJECTIVES

Since 2016, Canada has allowed for euthanasia based on strict criteria under federal medical assistance in dying legislation. The purpose of this study was to determine how Canadian intensivists perceive medical assistance in dying and whether they believe their approach to withdrawal of life-sustaining therapies has changed following introduction of medical assistance in dying.

DESIGN

Electronic survey.

SETTING

Participants were recruited from 11 PICU programs and 14 adult ICU programs across Canada. All program leaders for whom contact information was available were approached for participation.

PARTICIPANTS

We invited intensivists and critical care trainees employed between December 2019 and May 2020 to participate using a snowball sampling technique in which department leaders distributed study information. All responses were anonymous. Quantitative data were analyzed using descriptive statistics. Categorical variables were analyzed using Pearson chi-square test.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

We obtained 150 complete questionnaires (33% response rate), of which 50% were adult practitioners and 50% pediatric. Most were from academic centers (81%, n = 121). Of respondents, 86% (n = 130) were familiar with medical assistance in dying legislation, 71% in favor, 14% conflicted, and 11% opposed. Only 5% (n = 8) thought it had influenced their approach to withdrawal of life-sustaining therapies. Half of participants had no standardized protocol for withdrawal of life-sustaining therapies in their unit, and 41% (n = 62) had observed medications given in disproportionately high doses during withdrawal of life-sustaining therapies, with 13% having personally administered such doses. Most (80%, n = 120) had experienced explicit requests from families to hasten death, and almost half (47%, n = 70) believed it was ethically permissible to intentionally hasten death following withdrawal of life-sustaining therapies.

CONCLUSIONS

Most Canadian intensivists surveyed do not think that medical assistance in dying has changed their approach to end of life in the ICU. A significant minority are ethically conflicted about the current approach to assisted dying/euthanasia in Canada. Almost half believe it is ethical to intentionally hasten death during withdrawal of life-sustaining therapies if death is expected.

UK Public's Views and Perceptions About the Legalisation of Assisted Dying and Assisted Suicide

Current debates about assisted dying and assisted suicide cover a series of medical, legal, moral, ethical and religious aspects. Yet, public views on the subject remain underexplored and, therefore, not always accounted for in the formation of public policy. This paper reports on empirical data from a cross-sectional study in the UK in 2019, which examines public views about the legalisation of assisted dying and assisted suicide, by means of a self-administered Qualtrics-based survey (self-devised vignettes). A combination of simple random and convenience sampling was used. Participants (n = 297) state their preference that both assisted dying and assisted suicide should be legalised in the UK (n = 70%), while doctors should be legally allowed to support such wishes of patients with an incurable and painful illness from which they will die (n = 62.22%). The paper concludes that public opinion needs to be further accounted for in policymaking and discourses regarding patient autonomy and dignity of care.

Physician-Assisted Suicide and Euthanasia in the ICU: A Dialogue on Core Ethical Issues

OBJECTIVE

Many patients are admitted to the ICU at or near the end of their lives. Consequently, the increasingly common debate regarding physician-assisted suicide and euthanasia holds implications for the practice of critical care medicine. The objective of this article is to explore core ethical issues related to physician-assisted suicide and euthanasia from the perspective of healthcare professionals and ethicists on both sides of the debate.

SYNTHESIS

We identified four issues highlighting the key areas of ethical tension central to evaluating physician-assisted suicide and euthanasia in medical practice: 1) the benefit or harm of death itself, 2) the relationship between physician-assisted suicide and euthanasia and withholding or withdrawing life support, 3) the morality of a physician deliberately causing death, and 4) the management of conscientious objection related to physician-assisted suicide and euthanasia in the critical care setting. We present areas of common ground and important unresolved differences.

CONCLUSIONS

We reached differing positions on the first three core ethical questions and achieved unanimity on how critical care clinicians should manage conscientious objections related to physician-assisted suicide and euthanasia. The alternative positions presented in this article may serve to promote open and informed dialogue within the critical care community.

Limiting treatment and shortening of life: data from a cross-sectional survey in Germany on frequencies, determinants and patients' involvement

Background

Limiting treatment forms part of practice in many fields of medicine. There is a scarcity of robust data from Germany. Therefore, in this paper, we report results of a survey among German physicians with a focus on frequencies, aspects of decision making and determinants of limiting treatment with expected or intended shortening of life.

Methods

Postal survey among a random sample of physicians working in the area of five German state chambers of physicians using a modified version of the questionnaire of the EURELD Consortium. Information requested referred to the patients who died most recently within the last 12 months. Logistic regression was performed to analyse associations between characteristics of physicians and patients regarding limitation of treatment with expected or intended shortening of life.

Results

As reported elsewhere, 734 physicians responded (response rate 36.9%) and of these, 174 (43.2%) reported a withholding and 144 (35.7%) a withdrawal of treatment. Eighty one physicians estimated that there was at least some shortening of life as a consequence. In 25.9% of these cases hastening death had been discussed with the patient at the time or immediately prior to this action. Types of treatment most frequently limited was artificial nutrition (n = 35). Bivariate analysis indicates that limitation of treatment with possible or intended shortening of life for patients aged > 75 years is performed significantly more often (p = 0.007, OR 1.848). There was significantly less limitation of treatment in patients who died from cancer compared to patients with other causes of death (p = 0.01, OR 0.486). There was no significant statistical association with physicians’ religion, palliative care qualification or frequencies of limiting treatment.

Conclusions

In comparison to recent research from other European countries, limitation of treatment with expected or intended shortening of life is frequently performed amongst the investigated sample. The role of clinical and non-medical aspects possibly relevant for physicians’ decision about withholding or withdrawal of treatment with possible or intended shortening of life and reasons for non-involvement of patients should be explored in more detail by means of mixed method and interdisciplinary empirical-ethical analysis.

Intending, hastening and causing death in non-treatment decisions: a physician interview study

PURPOSE

To explore how physicians analyse their non-treatment decisions in light of the concepts of hastening, causing and intending the patient's death.

METHODS

Sixteen Norwegian physicians from relevant specialties were interviewed and the results analysed by systematic text condensation, a qualitative analysis framework.

RESULTS

The physicians' chief dilemma in non-treatment decisions was the attempt to achieve the proper balance for the level of treatment at life's end. Respondents framed their challenges in medical and not ethical terms. They treated the concepts of intending, hastening and causing the patient's death as alien to their practical deliberations and, for many, irrelevant to the moral appraisal of their end-of-life practices.

CONCLUSIONS

The core concepts of traditional medico-ethical analyses of end-of-life decision-making do not map the practical terrain well. Research on physician intentions must be designed and interpreted in light of this.

Determinants of acceptance of end-of-life interventions: a comparison between withdrawing life-prolonging treatment and euthanasia in Austria

Background

End-of-life decisions remain a hotly debated issue in many European countries and the acceptance in the general population can act as an important anchor point in these discussions. Previous studies on determinants of the acceptance of end-of-life interventions in the general population have not systematically assessed whether determinants differ between withdrawal of life-prolonging treatment (WLPT) and euthanasia (EUT).

Methods

A large, representative survey of the Austrian adult population conducted in 2014 (n = 1,971) included items on WLPT and EUT. We constructed the following categorical outcome: (1) rejection of both WLPT and EUT, (2) approval of WLPT but rejection of EUT, and (3) approval of both WLPT and EUT. The influence of socio-demographics, personal experiences, and religious and socio-cultural orientations on the three levels of approval were assessed via multinomial logistic regression analysis.

Results

Higher education and stronger socio-cultural liberal orientations increased the likelihood of approving both WLPT and EUT; personal experience with end-of-life care increased only the likelihood of approval of WLPT; and religiosity decreased approval of EUT only.

Conclusion

This study found evidence for both shared (education, liberalism) and different (religiosity, care experiences) determinants for the acceptance of WLPT and EUT.

Are physicians' estimations of future events value-impregnated? Cross-sectional study of double intentions when providing treatment that shortens a dying patient's life

The aim of the present study was to corroborate or undermine a previously presented conjecture that physicians' estimations of others' opinions are influenced by their own opinions. We used questionnaire based cross-sectional design and described a situation where an imminently dying patient was provided with alleviating drugs which also shortened life and, additionally, were intended to do so. We asked what would happen to physicians' own trust if they took the action described, and also what the physician estimated would happen to the general publics' trust in health services. Decrease of trust was used as surrogate for an undesirable action. The results are presented as proportions with a 95 % Confidence Interval (CI). Statistical analysis was based on inter-rater agreement (Weighted Kappa)-test as well as χ (2) test and Odds Ratio with 95 % CI. We found a moderate inter-rater agreement (Kappa = 0.552) between what would happen with the physicians' own trust in healthcare and their estimations of what would happen with the general population's trust. We identified a significant difference between being pro et contra the treatment with double intentions and the estimation of the general population's trust (χ(2) = 72, df = 2 and p < 0.001). Focusing on either decreasing or increasing own trust and being pro or contra the action we identified a strong association [OR 79 (CI 25-253)]. Although the inter-rater agreement in the present study was somewhat weaker compared to a study about the explicit use of the term 'physicians assisted suicide' we found that our hypothesis-physicians' estimations of others' opinions are influenced by their own opinions-was corroborated. This might have implications in research as well as in clinical decision-making. We suggest that Merton's ideal of disinterestedness should be highlighted.

Forgoing artificial nutrition or hydration at the end of life: a large cross-sectional survey in Belgium

OBJECTIVES

To examine the frequency and characteristics of decisions to forgo artificial nutrition and/or hydration (ANH) at the end of life.

DESIGN

Postal questionnaire survey regarding end-of-life decisions (including ANH) to physicians certifying a large representative sample (n=6927) of Belgian death certificates in 2007.

SETTING

Flanders, Belgium, 2007.

PARTICIPANTS

Treating physicians of deceased patients.

RESULTS

Response rate was 58.4%. A decision to forgoANH occurred in 6.6% of all deaths (4.2% withheld,3.0% withdrawn). Being female, dying in a care home or hospital and suffering from nervous system diseases(including dementia) or malignancies were the most important patient-related factors positively associated with a decision to forgo ANH. Physicians indicated that the decision to forgo ANH had had some life-shortening effects in 77% of cases. There had been no consultation with the patient in 81%, mostly due to incapacity (coma or dementia). The family, colleague physicians and nurses were involved in decision making in 76%,41% and 62%, respectively.

CONCLUSIONS

A substantial number of deaths are preceded by a decision to forgo ANH in Belgium. These decisions, ethically laden and involving a considerable chance of life shortening, are mostly not preceded by discussion with the patient despite existing patient rights legislation. It is recommended that physicians and patients and their families alike dedicate ample time to the discussion of treatment options and communication about the possibility of forgoing ANH and that this discussion takes place earlier as part of overall end-of life care planning rather than at the very end of life.

End-of-life discontinuation of destination therapy with cardiac and ventilatory support medical devices: physician-assisted death or allowing the patient to die?

BACKGROUND

Bioethics and law distinguish between the practices of "physician-assisted death" and "allowing the patient to die."

DISCUSSION

Advances in biotechnology have allowed medical devices to be used as destination therapy that are designed for the permanent support of cardiac function and/or respiration after irreversible loss of these spontaneous vital functions. For permanent support of cardiac function, single ventricle or biventricular mechanical assist devices and total artificial hearts are implanted in the body. Mechanical ventilators extrinsic to the body are used for permanent support of respiration. Clinical studies have shown that destination therapy with ventricular assist devices improves patient survival compared to medical management, but at the cost of a substantial alteration in end-of-life trajectories. The moral and legal assessment of the appropriateness and permissibility of complying with a patient's request to electively discontinue destination therapy in a life-terminating act in non-futile situations has generated controversy. Some argue that complying with this request is ethically justified because patients have the right to request withdrawal of unwanted treatment and be allowed to die of preexisting disease. Other commentators reject the argument that acceding to an elective request for death by discontinuing destination therapy is 'allowing a patient to die' because of serious flaws in interpreting the intention, causation, and moral responsibility of the ensuing death.

SUMMARY

Destination therapy with cardiac and/or ventilatory medical devices replaces native physiological functions and successfully treats a preexisting disease. We posit that discontinuing cardiac and/or ventilatory support at the request of a patient or surrogate can be viewed as allowing the patient to die if--and only if--concurrent lethal pathophysiological conditions are present that are unrelated to those functions already supported by medical devices in destination therapy. In all other cases, compliance with a patient's request constitutes physician-assisted death because of the pathophysiology induced by the turning off of these medical devices, as well as the intention, causation, and moral responsibility of the ensuing death. The distinction between allowing the patient to die and physician-assisted death is pivotal to the moral and legal status of elective requests for death by discontinuing destination cardiac and/or ventilatory medical devices in patients who are not imminently dying. This distinction also represents essential information that must be disclosed to patients and surrogates in advance of consent to this type of therapy.

Physicians' experiences with end-of-life decision-making: survey in 6 European countries and Australia

BACKGROUND

In this study we investigated (a) to what extent physicians have experience with performing a range of end-of-life decisions (ELDs), (b) if they have no experience with performing an ELD, would they be willing to do so under certain conditions and (c) which background characteristics are associated with having experience with/or being willing to make such ELDs.

METHODS

An anonymous questionnaire was sent to 16,486 physicians from specialities in which death is common: Australia, Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland.

RESULTS

The response rate differed between countries (39-68%). The experience of foregoing life-sustaining treatment ranged between 37% and 86%: intensifying the alleviation of pain or other symptoms while taking into account possible hastening of death between 57% and 95%, and experience with deep sedation until death between 12% and 46%. Receiving a request for hastening death differed between 34% and 71%, and intentionally hastening death on the explicit request of a patient between 1% and 56%.

CONCLUSION

There are differences between countries in experiences with ELDs, in willingness to perform ELDs and in receiving requests for euthanasia or physician-assisted suicide. Foregoing treatment and intensifying alleviation of pain and symptoms are practiced and accepted by most physicians in all countries. Physicians with training in palliative care are more inclined to perform ELDs, as are those who attend to higher numbers of terminal patients. Thus, this seems not to be only a matter of opportunity, but also a matter of attitude.

Competency and educational needs in palliative care

PURPOSE

To explore general practitioners' (GPs') and nurses' self assessment of professional education, competency and educational needs in palliative care.

METHODS

All 897 registered GPs and all 933 registered home care nurses in the Province of Styria/Austria were sent postal questionnaires to evaluate their professional training in (i) pain control and symptom management, (ii) handling psychosocial needs and (iii) ability to cope with work-related distress.

RESULTS

61.8% of 546 evaluable respondents felt not at all or not sufficiently prepared for palliative care by their professional education (GPs: 70%, nurses: 50.4%). GPs rated the competency of their professional guild significantly higher and their educational needs significantly lower than nurses (p<0.01). Both, GPs and nurses emphasised a great need for education in the area of neuropsychiatric symptom management.

CONCLUSION

Our results provide a detailed analysis of needs and may help to target goals for training seminars in palliative care.