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Jones DA. 'Assisted dying' as a comforting heteronomy: the rejection of self-administration in the purported act of self-determination. New Bioeth 2024; 30:103-122. [PMID: 38289327 DOI: 10.1080/20502877.2024.2307698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
'Assisted dying' (an umbrella term for euthanasia and/or assisted suicide) is frequently defended as an act of autonomous self-determination in death but, given a choice, between 93.3% and 100% of patients are reluctant to self-administer (median 99.5%). If required to self-administer, fewer patients request assisted death and, of these, a sizable proportion do not self-administer but die of natural causes. This manifest avoidance runs counter to the concept of autonomous self-determination, even on the supposition that suicide could truly be autonomous. The avoidance of self-administration does not show that self-administration, when it occurs, is necessarily autonomous. It suggests, rather, that there are other frames by which assisted dying is being understood. One such is desire for medical control, a desire shared by patients and doctors. Such a frame is not directed towards an exacting autonomy (self-directed action by the patient) but towards a comforting heteronomy (letting the doctor take control).
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Affiliation(s)
- David Albert Jones
- Anscombe Bioethics Centre, Oxford, UK
- School of Theology, St Mary's University, Twickenham, UK
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Jox RJ. Of Slopes and Ropes: Learning from the Diversity of European Regulations of Assisted Dying. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:84-87. [PMID: 37879028 DOI: 10.1080/15265161.2023.2256281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
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Güth U, Junker C, McMillan S, Elfgen C, Schneeberger AR. Long-term experience on assisted suicide in Switzerland: dementia, mental disorders, age-related polymorbidity and the slippery slope argument. Public Health 2023; 223:249-256. [PMID: 37690397 DOI: 10.1016/j.puhe.2023.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/14/2023] [Accepted: 08/01/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVES According to the Swiss medico-ethical guidelines valid between 2004 and 2018, the key criterion for assisted suicide (AS) was that the patients who wished to die suffered with a disease leading to death in the foreseeable future. Critics of AS fears that broadening of the medical indications will lead to an uncontrolled expansion to persons who are not terminally ill (slippery slope argument). We evaluated to what extent this broadening took place in practice over time. STUDY DESIGN Retrospective national cohort study. METHODS By using data of the Swiss Federal Statistical Office, we analyzed the long-term development of AS in Switzerland over a 20-year period (1999-2018; n = 8738 cases). We classified the cases into one of three categories regarding the aforementioned key criterion for AS. RESULTS In 43.6% of AS cases, the criterion 'end of life is near' was met. In 5.3% of cases, this criterion was not met (4.7%: mental disorders; 0.6%: dementia). In 51.1% of cases, the reason underlying AS comprised several, mostly age-related diseases and/or functional impairments; the aforementioned key criterion, however, was probably not met in most of the cases. Over time, the number of cases doubled over each 5-year period; this increase occurred similarly for the three categories. CONCLUSION The fact that many AS cases took place outside the valid medico-ethical guidelines might be interpreted as a development in the idea of the slippery slope argument. The fact that the percentage distribution of these cases remained unchanged over time argues against it.
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Affiliation(s)
- U Güth
- Brust-Zentrum Zürich, Department of Breast Surgery, Seefeldstrasse 214, Zurich CH-8008, Switzerland; University of Basel, Faculty of Medicine, Klingelbergstrasse 61, Basel CH-4056, Switzerland.
| | - C Junker
- Federal Statistical Office, Espace de l'Europe 10, Neuchâtel CH-2010, Switzerland.
| | - S McMillan
- Brust-Zentrum Zürich, Department of Breast Surgery, Seefeldstrasse 214, Zurich CH-8008, Switzerland.
| | - C Elfgen
- Brust-Zentrum Zürich, Department of Breast Surgery, Seefeldstrasse 214, Zurich CH-8008, Switzerland; University of Witten/Herdecke, Faculty of Medicine; Alfred-Herrhausen-Strasse 50, 58448 Witten, Germany.
| | - A R Schneeberger
- University of California San Diego, Department of Psychiatry, 8950 Villa La Jolla Drive, La Jolla, CA 92037, USA.
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Güth U, Junker C, Elger BS, Elfgen C, Montagna G, Schneeberger AR. Conventional and assisted suicide in Switzerland: Insights into a divergent development based on cancer-associated self-initiated deaths. Cancer Med 2023; 12:17296-17307. [PMID: 37554017 PMCID: PMC10501282 DOI: 10.1002/cam4.6323] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 06/04/2023] [Accepted: 06/23/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND We tested the hypothesis of supporters of assisted dying that assisted suicide (AS) might be able to prevent cases of conventional suicide (CS). METHODS By using data from the Federal Statistical Office, we analyzed the long-term development of 30,756 self-initiated deaths in Switzerland over a 20-year period (1999-2018; CS: n = 22,018, AS: n = 8738), focusing on people suffering from cancer who died from AS or CS. RESULTS While cancer was the most often listed principal disease for AS (n = 3580, 41.0% of AS cases), cancer was listed in only a small minority of CS cases (n = 832, 3.8% of CS cases). There was a significant increase in the absolute number of cancer-associated AS cases: comparing four 5-year periods, there was approximately a doubling of cases every 5 years (1999-2003: n = 228 vs.2004-2008: n = 474, +108% compared with the previous period; 2009-2013: n = 920, +94%; 2014-2018: n = 1958, +113%). The ratio of cancer-associated AS in relationship with all cancer-associated deaths increased over time to 2.3% in the last observation period (2014-2018). In parallel, the numbers of cancer-associated CS showed a downward trend only at the beginning of the observation period (1999-2003, n = 240 vs. 2004-2008, n = 199, -17%). Thereafter, the number of cases remained stable in the subsequent 5-year period (2009-2013, n = 187, -6%), and increased again toward the most recent period (2014-2018, n = 206, +10%). CONCLUSION The assumption that, with the increasingly accessible option of AS for patients with cancer, CS suicide will become "superfluous" cannot be confirmed. There are strong reasons indicating that situations and circumstances of cancer-associated CS are different from those for cancer-associated AS.
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Affiliation(s)
- Uwe Güth
- Department of Breast SurgeryBrust‐Zentrum ZürichZurichSwitzerland
- Faculty of MedicineUniversity of BaselBaselSwitzerland
| | | | - Bernice Simone Elger
- Institute for Biomedical EthicsUniversity of BaselBaselSwitzerland
- Center for Legal MedicineUniversity of GenevaGenèveSwitzerland
| | - Constanze Elfgen
- Department of Breast SurgeryBrust‐Zentrum ZürichZurichSwitzerland
- Faculty of MedicineUniversity of Witten/HerdeckeWittenGermany
| | - Giacomo Montagna
- Breast Service, Department of SurgeryMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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van Eenennaam RM, Kruithof W, Beelen A, Bakker LA, van Eijk RPA, Maessen M, Baardman JF, Visser-Meily JMA, Veldink JH, van den Berg LH. Frequency of euthanasia, factors associated with end-of-life practices, and quality of end-of-life care in patients with amyotrophic lateral sclerosis in the Netherlands: a population-based cohort study. Lancet Neurol 2023; 22:591-601. [PMID: 37353279 DOI: 10.1016/s1474-4422(23)00155-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis is a progressive and lethal neurodegenerative disease that is at the forefront of debates on regulation of assisted dying. Since 2002, when euthanasia was legally regulated in the Netherlands, the frequency of this end-of-life practice has increased substantially from 1·7% of all deaths in 1990 and 2005 to 4·5% in 2015. We aimed to investigate whether the frequency of euthanasia in patients with amyotrophic lateral sclerosis had similarly increased since 2002, and to assess the factors associated with end-of-life practices and the quality of end-of-life care in patients with this disease. METHODS Using data from the Netherlands ALS registry, we did a population-based cohort study of clinicians and informal caregivers of patients with amyotrophic lateral sclerosis to assess factors associated with end-of-life decision making and the quality of end-of-life care. We included individuals who were diagnosed with amyotrophic lateral sclerosis according to the revised El-Escorial criteria, and who died between Jan 1, 2014, and Dec 31, 2016. We calculated the frequency of euthanasia in patients with amyotrophic lateral sclerosis from reports made to euthanasia review committees (ERCs) between 2012 and 2020. Results were compared with clinic-based survey studies conducted in 1994-2005. End-of-life practices were end-of-life decisions by a clinician when hastening of death was considered as the potential, probable, or definite effect comprising euthanasia, physician-assisted suicide, ending of life without explicit request, forgoing life-prolonging treatment, and intensified alleviation of symptoms. FINDINGS Between Jan 1, 2012, and Dec 31, 2020, 4130 reports of death from amyotrophic lateral sclerosis were made to ERCs, of which 1014 were from euthanasia or physician-assisted suicide (mean frequency 25% [SD 3] per year). Sex and gender data were unavailable from the ERC registry. Of 884 patients with amyotrophic lateral sclerosis who died between Jan 1, 2014, and Dec 31, 2016, their treating clinician was identified for 731 and a caregiver was identified for 741, of whom 356 (49%) and 450 (61%), respectively, agreed to participate in the population-based survey study. According to clinicians, end-of-life practices were chosen by 280 (79%) of 356 patients with amyotrophic lateral sclerosis who died. The frequency of euthanasia in patients with amyotrophic lateral sclerosis in 2014-16 (141 [40%] of 356 deaths in patients with amyotrophic lateral sclerosis) was higher than in 1994-98 (35 [17%] of 203) and 2000-05 (33 [16%] of 209). Median survival of patients with amyotrophic lateral sclerosis from diagnosis was 15·9 months (95% CI 12·6-17·6) for those who chose euthanasia and 16·1 months (13·4-19·1) for those who did not choose euthanasia (hazard ratio 1·07, 95% CI 0·85-1·34; p=0·58). According to caregivers, compared with other end-of-life practices, patients with amyotrophic lateral sclerosis choosing euthanasia commonly reported reasons to hasten death as no chance of improvement (53 [56%] of 94 patients who chose euthanasia vs 28 [39%] of 72 patients who chose other end-of-life practices), loss of dignity (47 [50%] vs 15 [21%]), dependency (34 [36%] vs five [7%]), and fatigue or extreme weakness (41 [44%] vs 14 [20%]). According to caregivers, people with amyotrophic lateral sclerosis-whether they chose euthanasia or did not-were satisfied with the general quality (83 [93%] of 89 patients who chose euthanasia vs 73 [86%] of 85 patients who did not) and availability (85 [97%] of 88 vs 81 [91%] of 90) of end-of-life care. INTERPRETATION The proportion of patients with amyotrophic lateral sclerosis who chose euthanasia in the Netherlands has increased since 2002. The choice of euthanasia was not associated with disease or patient characteristics, depression or hopelessness, or the availability or quality of end-of-life care. The choice of euthanasia had no effect on overall survival. Future studies could focus on the effect of discussing end-of-life options on quality of life as part of multidisciplinary care throughout the course of the disease, to reduce feelings of loss of autonomy and dignity in patients living with amyotrophic lateral sclerosis. FUNDING Netherlands ALS Foundation.
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Affiliation(s)
- Remko M van Eenennaam
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Centre of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Willeke Kruithof
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Centre of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Anita Beelen
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Centre of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Leonhard A Bakker
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Centre of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Ruben P A van Eijk
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Biostatistics & Research Support, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Maud Maessen
- University Center for Palliative Care, Inselspital University Hospital Bern, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Joost F Baardman
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Johanna M A Visser-Meily
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Centre of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Jan H Veldink
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Leonard H van den Berg
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands.
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Montagna G, Junker C, Elfgen C, Schneeberger AR, Güth U. Long-term development of assisted suicide in Switzerland: analysis of a 20-year experience (1999-2018). Swiss Med Wkly 2023; 153:40010. [PMID: 36971666 DOI: 10.57187/smw.2023.40010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
AIMS OF THE STUDY The legalisation of assisted suicide is one of the most debated topics in the field of medical ethics worldwide. In countries in which assisted suicide is not legal, public discussions about its approval also encompass considerations of the long-term consequences that such legalisation would bring, for example, how many people will use this option, from what conditions would they be suffering, would there be differences between male and female assisted suicide and which developments and trends could be expected if there were to be a marked increase of cases of assisted suicide over time? METHODS In order to answer these questions, we present the development of assisted suicide in Switzerland over a 20-year period (1999-2018; 8738 cases) using data from the Swiss Federal Statistical Office. RESULTS During the observation period, the number of assisted suicides rose significantly: when four 5-year periods (1999-2003, 2004-2008, 2009-2013, 2014-2018) were analysed, the number of assisted suicide cases doubled over each period compared with the preceding one (Χ = 206.7, 270.4 and 897.4; p <0.001). The percentage of assisted suicides among all deaths rose from 0.2% (1999-2003; n = 582) to 1.5% (2014-2018: n = 4820). The majority of people who chose assisted suicide were elderly, with increasing age over time (median age in 1999-2003: 74.5 years vs 2014-2018: 80 years), and with a predominance of women (57.2% vs 42.8%). The most common underlying condition for assisted suicide was cancer (n = 3580, 41.0% of all assisted suicides). Over time, assisted suicide increased similarly for all underlying conditions; however, the proportion in each disease group remained unchanged. CONCLUSIONS It is a matter of one's viewpoint whether the rise of assisted suicide cases should be considered alarming or not. These figures reflect an interesting social development but still do not appear to represent a mass phenomenon.
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Affiliation(s)
- Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
- n>Breast Centre, University of Basel, Switzerland
| | | | - Constanze Elfgen
- Breast Centre Zurich, Switzerland
- Faculty of Medicine, University of Witten/Herdecke, Witten, Germany
| | - Andres R Schneeberger
- Psychiatric Services Grisons, Chur, Switzerland
- Psychiatric Hospital, University of Zurich, Switzerland
- Albert Einstein College of Medicine, New York, USA
| | - Uwe Güth
- Breast Centre Zurich, Switzerland
- Faculty of Medicine, University of Basel, Switzerland
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Mroz S, Deliens L, Cohen J, Chambaere K. Developments after the liberalization of laws concerning assisted dying—experience from Belgium and other countries. DEUTSCHES ÄRZTEBLATT INTERNATIONAL 2022. [DOI: 10.3238/arztebl.m2022.0378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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8
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Orsolya Friedrich, Claudia Bozzaro (Hrsg) (2021) Philosophie der Medizin. Ethik Med 2022. [DOI: 10.1007/s00481-022-00721-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Byrnes E, Ross AI, Murphy M. A Systematic Review of Barriers and Facilitators to Implementing Assisted Dying: A Qualitative Evidence Synthesis of Professionals' Perspectives. OMEGA-JOURNAL OF DEATH AND DYING 2022:302228221116697. [PMID: 35929771 DOI: 10.1177/00302228221116697] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Assisted dying is a divisive topic and draws both lamenting and approving commentary from political, medical, legal, and philosophical domains. This systematic review and qualitative evidence synthesis aims to identify the factors that healthcare professionals experience when working within assisted dying frameworks. PRISMA guidelines for systematic reviews were followed. Search results yielded 15,426 papers with 39 papers meeting inclusion criteria for this review. Remaining papers were subjected to critical appraisal and a thematic synthesis. Eight themes fell under the domain of 'barrier' and represented different personal and professional factors that hinder professionals from delivering assisted dying healthcare. Five themes came under the domain of 'facilitators' and represent factors that contribute to the smooth implementation and delivery of assisted dying services. Health professionals experience a range of factors that both impede and propel delivery of assisted dying frameworks.
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Affiliation(s)
- Eric Byrnes
- Department of Clinical Psychology, School of Applied Psychology, University College Cork, Clare, Ireland
- Cork Mental Health Services, Cork/Kerry Community Healthcare, Health Service Executive, Cork, Ireland
| | - Alasdair Iain Ross
- Department of Clinical Psychology, School of Applied Psychology, University College Cork, Clare, Ireland
- Cork Mental Health Services, Cork/Kerry Community Healthcare, Health Service Executive, Cork, Ireland
| | - Mike Murphy
- Department of Clinical Psychology, School of Applied Psychology, University College Cork, Clare, Ireland
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Roy K. Medical Aid in Dying: What Every Nurse Needs to Know. Am J Nurs 2022; 122:30-37. [PMID: 35149608 DOI: 10.1097/01.naj.0000822660.87763.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The number of U.S. states legalizing medical aid in dying for patients with terminal diseases and survival prognoses of six months or less is increasing. At press time, 10 states and the District of Columbia have legalized such aid. But because terminal illnesses without clear prognoses are not covered under these laws, some patients are forced to seek medical aid in dying outside the country.The nurse's role regarding aid in dying is poorly defined, and must be clarified. Currently, nurses and other providers have many misconceptions and fears about providing patients and families with the relevant education. Nurses need to have accurate knowledge and understanding of aid in dying, so they can advocate for those requesting this option; ensure equitable access; and provide them with guidance, support, and resources. An interdisciplinary approach is essential.This article provides background information on aid in dying in the United States, discusses the nurse's role, offers an illustrative case report, and addresses nursing implications.
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Affiliation(s)
- Kaveri Roy
- Kaveri Roy (she/her) is a Distinguished Teaching Assistant Professor in the School of Nursing at MGH Institute of Health Professions, Boston. Contact author: . The author has disclosed no potential conflicts of interest, financial or otherwise. A podcast with the author is available at www.ajnonline.com
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Briggs S, Lindner R, Goldblatt MJ, Kapusta N, Teising M. Psychoanalytic understanding of the request for assisted suicide. THE INTERNATIONAL JOURNAL OF PSYCHOANALYSIS 2022; 103:71-88. [PMID: 35168484 DOI: 10.1080/00207578.2021.1999773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The legalisation of assisted dying, including euthanasia and physician assisted suicide, is increasing in countries across the world and constitutes a key contemporary debate, reflecting social changes, in which two views of suicide conflict; that (1) rational reasons justify assisted suicide, providing dignity and control of terminal illness and (2) suicidal wishes are driven by unconscious and disturbing internal conflicts. In this paper we explore the unconscious motives and meanings of requests for assisted suicide. Although there is a paucity of psychoanalytic literature on the subject, and an absence of practice examples, we make two links, firstly, with the literature of palliative and end of life care, and, secondly, with psychoanalytic understanding of suicide, in order to develop the view that unconscious factors are crucial to understanding requests for assisted suicide. We provide an illustrative case example of psychodynamic psychotherapy with a 94-year-old woman, drawing out theoretical and practice implications. We show that unconscious factors and motives lie behind apparently rational requests for assisted suicide, and attention to these through psychoanalytically informed treatment can bring about therapeutic change.
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Affiliation(s)
- Stephen Briggs
- Clinical Education, Development and Research (CEDAR), Department of Psychology, University of Exeter, Exeter, UK
| | - Reinhard Lindner
- Faculty of Social Sciences, University of Kassel, Kassel, Germany
| | | | - Nestor Kapusta
- Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Vienna, Austria
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Montagna G, Junker C, Elfgen C, Schneeberger A, Güth U. Assisted suicide in patients with cancer. ESMO Open 2022; 7:100349. [PMID: 35066409 PMCID: PMC8789521 DOI: 10.1016/j.esmoop.2021.100349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/14/2021] [Accepted: 11/19/2021] [Indexed: 11/30/2022] Open
Abstract
Background There are limited data on the long-term development and trends of assisted suicide (AS) among cancer patients. Patients and methods Using data of the Swiss Federal Statistical Office, we analyzed AS trends over an 18-year period (1999-2016; total number of cases = 6553). Results Among patients who underwent AS, cancer was the most common underlying disease (n = 2704, 41.3% of all AS cases). The most common cancer types were lung (14.0% of cancer-related AS cases), breast (11.0%) and prostate (10.1%). There was a slight preponderance of men compared with women (51.5% versus 48.5%). The proportion of AS cases within cancer types did not change over time. The ratio of cancer-related AS cases in relationship with all cancer-related deaths increased from 0.3% at the beginning of the study period (1999-2003) to 2.1% from 2014 to 2016 (change of age-standardized rates for men: +488%; for women: +417%). At the end of the study period (2014-2016), there were only minor differences between cancer-specific ratios, highest and lowest range: 1.1% (liver cancer) and 2.8% (breast, esophageal and lip/oral cavity/oropharynx cancer). Individuals who underwent AS because of cancer were considerably younger than those who choose AS on account of other diseases (73 years versus 80 years). The median age of people with cancer-related AS was similar to that of all cancer-related deaths (74 years): for women, the median age of cancer-related AS was 72, whereas for men it was 75. The median age at which AS took place increased over time. Conclusions During the study period, the proportion of people who chose cancer-related AS has approximately sextupled. However, AS among cancer patients remains rare and represents only ∼2% of all cancer-related deaths. Cancer was the most common underlying disease for AS (41.3% of all AS cases). The ratio of cancer-related AS to all cancer-related deaths has sextupled over time: from 0.3% (1991-2003) to 2.1% (2014-2016). There were only minor differences between the cancer-specific ratios; in 2014-2016, ranges were between 1.1% and 2.8%. Individuals with cancer-related AS were younger than those who choose AS due to other diseases (73 vs. 80 years). The median age of people with cancer-related AS (73 years) was similar to that of all cancer-related deaths (74 years).
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Schildmann J, Junghanss C, Oldenburg M, Schuler U, Trümper L, Wörmann B, Winkler E. Role and responsibility of oncologists in assisted suicide. Practice and views among members of the German Society of Haematology and Medical Oncology. ESMO Open 2021; 6:100329. [PMID: 34896697 PMCID: PMC8666647 DOI: 10.1016/j.esmoop.2021.100329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/08/2021] [Accepted: 11/04/2021] [Indexed: 11/16/2022] Open
Abstract
Background Physician-assisted suicide (PAS) is a controversial practice and regulatory frameworks differ regarding assigned physicians' roles. This study explores clinical experience and views of German oncologists concerning ethically and legally relevant aspects of PAS after change of the law. Materials and methods An online survey was conducted among members of the German Society of Haematology and Medical Oncology (DGHO) in March 2021. Descriptive analysis, bivariate and multivariable logistic regression of quantitative data on determinants related to (un)willingness to assist with suicide as well qualitative analysis of free-text comments were carried out. Results Seven hundred and forty-five of 3588 DGHO members responded (20.8%). Of these, 29.9% reported requests for a lethal drug and 3.0% (n = 22) reported to have assisted with suicide. Almost half of them (47.0%, n = 350) objected to providing PAS, whereas 45.9% indicated a willingness at least under certain conditions. Of those respondents who did not object to PAS, 25.4% would also consider assistance if those willing to die had a psychiatric disease and 10.2% if requestors had no disease at all. A majority viewed a role for physicians regarding different tasks associated with assisted suicide. Respondents with <10 years of professional experience, working in hospital with religious affiliation and with subspecialisation in palliative care were significantly less frequently willing to assist suicide. Conclusions Respondents are divided in their personal attitudes towards PAS but a majority supports involvement of physicians regarding different tasks related to assisted suicide. Data about the practice and envisaged professional role may inform development of an acceptable ethico-legal framework for a controversial practice. In Germany, as in other countries, assisted suicide has become lawful more recently. To be able to develop guidance on the highly controversial subject, empirical data on practice and related aspects are needed. 30% of responding oncologists report requests for lethal drugs by their patients and 3% have assisted with suicide. Compared with 2015, significantly more oncologists report requests for lethal drugs and willingness to assist with suicide. Palliative care qualification and less professional experience were negatively associated with willingness to assist suicide.
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Affiliation(s)
- J Schildmann
- Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Medical Faculty of Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
| | - C Junghanss
- Division of Medicine, Department of Hematology, Oncology and Palliative Medicine, University Medical Center, Rostock, Germany
| | - M Oldenburg
- German Society of Haematology and Medical Oncology (DGHO), Berlin, Germany
| | - U Schuler
- Department of Internal Medicine I, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - L Trümper
- Department of Hematology and Medical Oncology, University Medicine Göttingen, Göttingen, Germany
| | - B Wörmann
- German Society of Haematology and Medical Oncology (DGHO), Berlin, Germany; Department of Internal Medicine, Hematology/Oncology and Tumor Immunology, Charité University Medicine, Berlin, Germany
| | - E Winkler
- National Center for Tumor Diseases, Section for Translational Medical Ethics, Department of Medical Oncology, University Hospital, Heidelberg, Germany
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14
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Borasio GD, Jox R, Taupitz J, Wiesing U. Yes, This Is the Society in Which We Want to Live. J Palliat Med 2021; 24:659-660. [PMID: 33945324 DOI: 10.1089/jpm.2021.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gian Domenico Borasio
- Palliative and Supportive Care Service, and Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ralf Jox
- Palliative and Supportive Care Service, and Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jochen Taupitz
- Institute for German, European, and International Medical Law, Public Health Law and Bioethics of the Universities of Heidelberg and Mannheim, Mannheim, Germany
| | - Urban Wiesing
- Institute of Ethics and History of Medicine, University of Tuebingen, Tuebingen, Germany
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15
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Tomczyk M, Dieudonné-Rahm N, Jox RJ. A qualitative study on continuous deep sedation until death as an alternative to assisted suicide in Switzerland. BMC Palliat Care 2021; 20:67. [PMID: 33990204 PMCID: PMC8122537 DOI: 10.1186/s12904-021-00761-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/16/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND According to the European Association for Palliative Care, decisions regarding palliative sedation should not be made in response to requests for assisted dying, such as euthanasia or assisted suicide. However, several studies show that continuous deep sedation until death (CDSUD) - a particular form of sedation - has been considered as an alternative to these practices in some countries. In Switzerland, where assisted suicide is decriminalized and CDSUD is not legally regulated, no studies have comprehensively investigated their relation. Our study aimed to identify and describe the experience among palliative care physicians of CDSUD as a potential alternative to assisted suicide in the French-speaking part of Switzerland. METHODS We performed an exploratory multicentre qualitative study based on interviews with palliative care physicians in the French-speaking part of Switzerland and conducted linguistic and thematic analysis of all interview transcripts. The study is described in accordance with COREQ guidelines. RESULTS We included 10 interviews conducted in four palliative care units. Our linguistic analysis shows four main types of sedation, which we called 'rapid CDSUD', 'gradual CDSUD', 'temporary sedation' and 'intermittent sedation'. CDSUD (rapid or gradual) was not considered an alternative to assisted suicide, even if a single situation has been reported. In contrast, 'temporary' or 'intermittent sedation', although not medically indicated, was sometimes introduced in response to a request for assisted suicide. This was the fact when there were barriers to an assisted suicide at home (e.g., when transfer home was impossible or the patient wished not to burden the family). CONCLUSION These preliminary results can guide clinical, ethical, linguistic and legal reflection in this field and be used to explore this question more deeply at the national and international levels in a comparative, interdisciplinary and multiprofessional approach. They can also be useful to update Swiss clinical guidelines on palliative sedation in order to include specific frameworks on various sedation protocols and sedation as an alternative to assisted suicide. Potential negative impacts of considering palliative sedation as an alternative to assisted suicide should be nuanced by open and honest societal debate.
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Affiliation(s)
- Martyna Tomczyk
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland.
| | - Nathalie Dieudonné-Rahm
- Palliative Care Unit, Geneva University Hospitals, Chemin de la Savonnière 11, 1245 Collonge Bellerive, Geneva, Switzerland
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital & University of Lausanne, Av. de Provence 82, CH-1007, Lausanne, Switzerland
- Palliative & Supportive Care Service, Chair in Geriatric Palliative Care, Lausanne University Hospital & University of Lausanne, Av. Pierre-Decker 5, CH-1011, Lausanne, Switzerland
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Nath U, Regnard C, Lee M, Lloyd KA, Wiblin L. Physician-assisted suicide and physician-assisted euthanasia: evidence from abroad and implications for UK neurologists. Pract Neurol 2021; 21:205-211. [PMID: 33850034 DOI: 10.1136/practneurol-2020-002811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 11/04/2022]
Abstract
In this article, we consider the arguments for and against physician-assisted suicide (AS) and physician-assisted euthanasia (Eu). We assess the evidence around law and practice in three jurisdictions where one or both are legal, with emphasis on data from Oregon. We compare the eligibility criteria in these different regions and review the range of approved disorders. Cancer is the most common cause for which requests are granted, with neurodegenerative diseases, mostly motor neurone disease, ranking second. We review the issues that may drive requests for a physician-assisted death, such as concerns around loss of autonomy and the possible role of depression. We also review the effectiveness and tolerability of some of the life-ending medications used. We highlight significant variation in regulatory oversight across the different models. A large amount of data are missing or unavailable. We explore physician-AS and physician-assisted Eu within the wider context of end-of-life practice.
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Affiliation(s)
- Uma Nath
- Neurology, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, Tyne and Wear, UK
| | - Claud Regnard
- Palliative Medicine, St Oswald's Hospice, Newcastle upon Tyne, UK
| | - Mark Lee
- Palliative Medicine, St Benedict's Hospice, South Tyneside and Sunderland NHS Trust, Sunderland, UK
| | | | - Louise Wiblin
- Neurology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
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Möller HJ. The ongoing discussion on termination of life on request. A review from a German/European perspective. Int J Psychiatry Clin Pract 2021; 25:2-18. [PMID: 32729770 DOI: 10.1080/13651501.2020.1797097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Interest in the topic of termination of life has been growing for 2 decades. After legalisation of active euthanasia and assisted suicide (EAS) in the Netherlands in 2002, movements to implement similar laws started in other European countries. However, many people objected to legalisation on the basis of the experiences in the Netherlands and as a matter of principal. METHODS This selected and focussed review presents the theoretical discussions about EAS and describes the respective parliamentary discussions in Germany and the data and experiences in the Netherlands. It also considers people with mental disorders in the context of termination-of-life services. RESULTS So far, only a few European countries have introduced legislation on EAS. Legalisation of EAS in the Netherlands resulted in an unexpectedly large increase in cases. The number of people with mental disorders who terminate their lives on request remains low. CONCLUSIONS Experience from the Netherlands shows that widening criteria for EAS has problematic consequences.KEY POINTSTermination of life on request, which a subgroup of people support, is a matter of ongoing debate.Because of several problematic aspects, including ethical considerations, only a few countries in the world allow active euthanasia or assisted suicide.Even if euthanasia is well regulated, legalising it can have problematic consequences that are difficult to control, such as an unwanted excessive increase in euthanasia cases.The well-documented experiences with the euthanasia law in the Netherlands serve as an example of what is to be expected when euthanasia is legalised.We need to pay close attention to the relationship between suicide and suicide prevention on the one hand and euthanasia acts and promotion of euthanasia on the other.Further ethical, psychological and legal research is needed. In particular, the role of palliative medicine in societies' approach to end-of-life care must be explored in much more detail.
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Affiliation(s)
- Hans-Jürgen Möller
- Department of Psychiatry, Ludwig-Maximilians-Universität Munich, Munich, Germany
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18
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Van Den Noortgate N, Van Humbeeck L. Medical assistance in dying and older persons in Belgium: trends, emerging issues and challenges. Age Ageing 2021; 50:68-71. [PMID: 32574355 DOI: 10.1093/ageing/afaa116] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Indexed: 11/13/2022] Open
Abstract
In 2002, the Belgian Act on euthanasia came into effect, regulating the intentional ending of life by a physician at the patient's explicit request. Subsequently, the number of reported euthanasia deaths increased every year. Specifically, the proportion of euthanasia deaths in older persons has risen significantly in the last few years. Since the conception of the Euthanasia Act, Belgian physicians have been confronted with challenges concerning euthanasia requests in older persons with polypathology, tiredness of life or dementia. By exploring these issues, this commentary highlights the importance of a meticulous and team-based assessment of the (i) seriousness of the underlying condition, (ii) voluntariness of the request and (iii) decisional capacity of the older person requesting euthanasia.
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Vilpert S, Borrat-Besson C, Borasio GD, Maurer J. Associations of end-of-life preferences and trust in institutions with public support for assisted suicide: evidence from nationally representative survey data of older adults in Switzerland. PLoS One 2020; 15:e0232109. [PMID: 32324815 PMCID: PMC7179897 DOI: 10.1371/journal.pone.0232109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/07/2020] [Indexed: 11/19/2022] Open
Abstract
The legality of euthanasia and assisted suicide (AS) and nature of regulations of these practices remain controversial and the subject of lively debate among experts and the general public. Our study investigates attitudes and behaviours towards AS among older adults in Switzerland where the practice of AS has a relatively long history and remains rather unregulated. We aim to explore how individuals' preferences regarding their end of life, as well as individuals' trust in institutions involved in the practice or control of AS are associated with attitudes and behaviours towards AS. We analyse nationally representative data of adults aged 55 and over from wave 6 (2015) of the Survey of Health, Ageing and Retirement in Europe (SHARE) in Switzerland (n = 2,145). While large majorities supported current legal arrangements around AS in Switzerland (81.7%) and stated that they could consider AS for themselves under certain circumstances (61.0%), only a minority either was a member of a right-to-die organisation already (4.9%) or stated they were likely to become a member of such an organisation (28.2%). Stated preferences for control over the end of life and for maintaining essential capabilities at the end of life showed a positive association with AS-related attitudes and behaviours, whereas preferences for feeling socially and spiritually connected, as well as for not being a burden displayed a negative association with our outcomes. Higher levels of trust in one's relative were positively associated with both support for the legality of AS and potential use of AS. A positive association was also found between trust in the Swiss legal system and support for the legality of AS. By contrast, trust in religious institutions displayed a negative association with all five AS-related attitudes and behaviours. Similarly, trust in healthcare insurance companies was negatively associated with potential use of AS. Taken together, older adults were generally supportive towards current practices regarding AS. This approval appears to be closely related to individuals' preferences and, at different extends, to trust in social and public institutions with regard to end-of-life issues, which is relatively high in Switzerland.
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Affiliation(s)
- Sarah Vilpert
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Swiss Centre of Expertise in the Social Sciences (FORS), University of Lausanne, Lausanne, Switzerland
| | - Carmen Borrat-Besson
- Swiss Centre of Expertise in the Social Sciences (FORS), University of Lausanne, Lausanne, Switzerland
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, University of Lausanne Medical Center, Lausanne, Switzerland
| | - Jürgen Maurer
- Faculty of Business and Economics, University of Lausanne, Lausanne, Switzerland
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Gamondi C, Pott M, Preston N, Payne S. Swiss Families' Experiences of Interactions with Providers during Assisted Suicide: A Secondary Data Analysis of an Interview Study. J Palliat Med 2020; 23:506-512. [DOI: 10.1089/jpm.2019.0286] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Claudia Gamondi
- Palliative and Supportive Care Service, Lausanne University Hospital, Lausanne, Switzerland
- Palliative and Supportive Care Clinic, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Murielle Pott
- HESAV, HES-SO//University of Applied Sciences Western Switzerland, Lausanne, Switzerland
| | - Nancy Preston
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
| | - Sheila Payne
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
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Dürst A, Spencer B, Büla C, Fustinoni S, Mazzocato C, Rochat E, Rubli Truchard E, Monod S, Jox RJ. Wish to Die in Older Patients: Development and Validation of Two Assessment Instruments. J Am Geriatr Soc 2020; 68:1202-1209. [DOI: 10.1111/jgs.16392] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/27/2020] [Accepted: 02/06/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Anne‐Véronique Dürst
- Service of Geriatric Medicine & Geriatric Rehabilitation University of Lausanne Hospital (CHUV) Lausanne Switzerland
| | - Brenda Spencer
- Centre for Primary Care and Public Health (Unisanté) University of Lausanne Lausanne Switzerland
| | - Christophe Büla
- Service of Geriatric Medicine & Geriatric Rehabilitation University of Lausanne Hospital (CHUV) Lausanne Switzerland
| | - Sarah Fustinoni
- Centre for Primary Care and Public Health (Unisanté) University of Lausanne Lausanne Switzerland
| | - Claudia Mazzocato
- Service of Palliative and Supportive Care Lausanne University Hospital (CHUV) Lausanne Switzerland
| | - Etienne Rochat
- Institute of Humanities in Medicine Lausanne University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
| | - Eve Rubli Truchard
- Service of Geriatric Medicine & Geriatric Rehabilitation University of Lausanne Hospital (CHUV) Lausanne Switzerland
- Chair in Geriatric Palliative Care Lausanne University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
| | - Stéfanie Monod
- General Health Department Ministry of Health and Social Action Lausanne Switzerland
| | - Ralf J. Jox
- Service of Palliative and Supportive Care Lausanne University Hospital (CHUV) Lausanne Switzerland
- Institute of Humanities in Medicine Lausanne University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
- Chair in Geriatric Palliative Care Lausanne University Hospital (CHUV) and University of Lausanne Lausanne Switzerland
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22
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Gamondi C, Fusi-Schmidhauser T, Oriani A, Payne S, Preston N. Family members' experiences of assisted dying: A systematic literature review with thematic synthesis. Palliat Med 2019; 33:1091-1105. [PMID: 31244384 DOI: 10.1177/0269216319857630] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Families' experiences of assisted dying are under-investigated and families are rarely considered in clinical guidelines concerning assisted dying. AIM To systematically review family experiences of assisted dying. DESIGN A systematic literature review using thematic synthesis. DATA SOURCES MEDLINE, Embase, CINAHL, AMED (Allied and Complementary Medicine) and PsycINFO databases (January 1992 to February 2019). Studies investigating families' experiences on the practice of legalised assisted dying were included. We excluded studies prior to legalisation within the jurisdiction, secondary data analysis and opinion papers. RESULTS Nineteen articles met the inclusion criteria. Publications were derived from four countries: The Netherlands, United States (Oregon, Washington and Vermont), Canada and Switzerland. Dutch studies predominately investigated family involvement in euthanasia, while Swiss and American studies only reported on assisted suicide. Eleven studies had a qualitative design, using predominately in-depth interviews; seven were retrospective surveys. Five analytical themes represented families' experiences in assisted dying: (1) context of the decision, (2) grounding the decision, (3) cognitive and emotional work, (4) experiencing the final farewell and (5) grief and bereavement. The results showed that families can be very involved in supporting patients seeking assisted dying, where open communication is maintained. Family involvement appeared to be influenced by the type of legislation in their country and the families' perception of the social acceptability of assisted dying. CONCLUSION Our data confirm that families across all jurisdictions are involved in assisted suicide decision and enactment. Family needs are under-researched, and clinical guidelines should incorporate recommendations about how to consider family needs and how to provide them with evidence-based tailored interventions.
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Affiliation(s)
- Claudia Gamondi
- 1 Palliative and Supportive Care Service, Department of Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.,2 Palliative and Supportive Care Clinic, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Tanja Fusi-Schmidhauser
- 2 Palliative and Supportive Care Clinic, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Anna Oriani
- 2 Palliative and Supportive Care Clinic, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Sheila Payne
- 3 International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Nancy Preston
- 3 International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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23
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Affiliation(s)
- Nancy Preston
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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