The Eluana Englaro Case: Cause of death after the withdrawal of artificial nutrition and hydration in a subject in a permanent vegetative state and with quadriplegia

Development and Validation of a Questionnaire investigating the Knowledge, Attitudes and Practices of Healthcare Workers in the Field of Anesthesiology concerning the Italian Law on Advance Healthcare Directives: a Pilot Study

Advance healthcare directives are legal documents, in which the patient, foreseeing a potential loss of capacity and autonomy, makes in advance decisions regarding future care and, in particular, end-of-life arrangements. In Italy, advance healthcare directives  are regulated by the Law 219 of 22 December 2017. Objectives of the study were: i) to develop and validate a questionnaire dedicated to evaluate the knowledge of the Law in a sample of 98 anesthesiologists, and ii) to shed light on the process of health-related decision-making and its determinants (age, gender, doctor/training resident, religious beliefs). A second part of the survey  not analyzed  in the present study, aimed to assess, through two simulated clinical scenarios, how patient' directives, relatives and the medical staff could influence physicians' clinical decision. Overall Cronbach's alpha coefficient of the questionnaire resulted 0.83. Three factors explaining up to 38.4% of total variance (communication and relationship with the patient; critical life-threatening situations and binding nature of the advance directive for the physician; and involvement of patients). Most of the doctors (58.7%) did not fully know the recent legislative provision. The lack of knowledge is critical in view of the specificity of the clinical area investigated (anesthesiology and intensive care), which has to cope with ethical issues. An adequate revision and implementation of the traditional curricula could help medical students and trainees develop the aptitudes and skills needed in their future profession.

Take-Home Messages from the COVID-19 Pandemic: Strengths and Pitfalls of the Italian National Health Service from a Medico-Legal Point of View

The World Health Organization (WHO) declared the outbreak of the Coronavirus disease-2019 (COVID-19) infection a pandemic on 11 March 2020. As of the end of October 2020, there were 50 million cases of infection and over one million deaths recorded worldwide, over 45,000 of which occurred in Italy. In Italy, the demand for intensive care over the course of this pandemic crisis has been exceptionally high, resulting in a severe imbalance between the demand for and availability of the necessary resources. This paper focuses on elements of preventive medicine and medical treatments in emergency and non-emergency situations which, based on the international scientific literature, may prove to be useful to physicians on a behavioral level and avert professional liability problems. In order to achieve this objective, we have performed a search on MEDLINE to find published articles related to the risks associated with the pandemic that contain useful suggestions and strategies for mitigating risks and protecting the safety of the population. The results have been collocated in line with these specific study areas.

The state of knowledge of young Italian medicolegal doctors on the law of provisions for informed consent and advance treatment directives: a multi-centric survey two years after the enactment of Law 219 of 2017

Background.

On 22 December 2017, Law No. 219 was approved in Italy entitled “Provisions on informed consent and advance treatment directives”. This article reports the results from a survey of the knowledge of medico-legal experts in Italy on these provisions, in addition to the ability of university healthcare facilities in Italy to implement the principles of this new law.

Methods.

A survey questionnaire was sent to members of a scientific society. The society had 357 members and represented more than 75% of doctors in training and 32 university healthcare facilities in Italy. 27 of those facilities and 45% of the society’s members participated in this enquiry.

Results.

The majority (68%) of those interviewed felt they had acquired an adequate knowledge of the law but only 60% of them were able to indicate how to file legally valid advance directives (60% vs. 40%); only 37% knew how to draft a shared care plan. 89% of the pool felt that legal recognition of patient self-determination enhanced the care relationship. 74% of the facilities analyzed have organized training activities on the contents of the law but only 26% have updated their informed consent forms and procedures. 60% of the facilities perform medico-legal consultation activities and in 15% of the facilities there has been resistance to applying the law.

Conclusion.

Many of the facilities have set up training activities but lack effective implementation of those activities. With increased knowledge and organization this could be remedied. (www.actabiomedica.it)

Shared care plan: an extraordinary tool for the personalization of medicine and respect for self-determination

BACKGROUND

On 22 December 2017, Law No. 219 was approved in Italy. This law provides citizens with effective tools with which to express healthcare decisions: namely, advance treatment directives (ATD) and shared care plans (SCP).

METHODS

This article presents an analysis of 70 SCP cases carried out in a tertiary hospital in Italy during the period between 01.02.2018 and 29.02.2020 inclusive.

RESULTS

In 90% of cases, the objective of the plan pertained to situations regarding patients' refusal of transfusions of blood components, the majority (97%) due to their belonging to the religious movement of Jehovah's Witnesses. 46% of the sample had drafted ATDs. The course of treatment recommended by the attending physicians was confirmed in 93% of the SCP cases. Trustees were appointed in 96% of cases. In 55% of cases, patients assigned trustees with attestative functions and the remaining 45% with creative functions. The results demonstrate that each patient personally dictates his or her wishes and the role assigned to the trustee. SCP meetings serve as a useful tool for providing the patient and his or her relatives with information, and for appointing a trustee. However, it has never been necessary to solicit the intervention of the trustee following a surgical operation.

CONCLUSIONS

The SCP has proven to be an essential tool in achieving the objective of personalised medicine. However, there is still notable passivity in its application. Further effort is required in order for it to become a common asset in clinical practice.

Suicide tourism: a pilot study on the Swiss phenomenon

While assisted suicide (AS) is strictly restricted in many countries, it is not clearly regulated by law in Switzerland. This imbalance leads to an influx of people-'suicide tourists'-coming to Switzerland, mainly to the Canton of Zurich, for the sole purpose of committing suicide. Political debate regarding 'suicide tourism' is taking place in many countries. Swiss medicolegal experts are confronted with these cases almost daily, which prompted our scientific investigation of the phenomenon. The present study has three aims: (1) to determine selected details about AS in the study group (age, gender and country of residence of the suicide tourists, the organisation involved, the ingested substance leading to death and any diseases that were the main reason for AS); (2) to find out the countries from which suicide tourists come and to review existing laws in the top three in order to test the hypothesis that suicide tourism leads to the amendment of existing regulations in foreign countries; and (3) to compare our results with those of earlier studies in Zurich. We did a retrospective data analysis of the Zurich Institute of Legal Medicine database on AS of non-Swiss residents in the last 5 years (2008-2012), and internet research for current legislation and political debate in the three foreign countries most concerned. We analysed 611 cases from 31 countries all over the world. Non-terminal conditions such as neurological and rheumatic diseases are increasing among suicide tourists. The unique phenomenon of suicide tourism in Switzerland may indeed result in the amendment or supplementary guidelines to existing regulations in foreign countries.