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Bosma F, Stoppelenburg A, van der Heide A, van de Vathorst S. Frequency of self-directed dying in the Netherlands: research protocol of a cross-sectional mixed-methods study. BMJ Open 2024; 14:e085240. [PMID: 38684276 PMCID: PMC11086523 DOI: 10.1136/bmjopen-2024-085240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/11/2024] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION In the Netherlands, assisting in suicide is allowed for physicians and regulated by the Termination of Life on Request and Assisted Suicide (review procedures) Act. However, some people decide to end their lives outside the medical domain, without a physician's help. Two approaches for such self-directed dying are voluntary stopping eating and drinking (VSED) and independently taking lethal medication attended by a confidant (ILMC). The frequency of deaths by either of these methods in the Netherlands was examined in 2007. Since then, there have been societal, political and healthcare developments which may have had an influence on the frequency of self-directed dying. The primary objective of this study is to estimate how many people in the Netherlands currently die by VSED or ILMC. Secondary objectives include providing insight in the characteristics and quality of dying of people who choose for self-directed dying. METHODS AND ANALYSIS This cross-sectional study consists of an online questionnaire study (January to February 2024) among a randomly drawn sample (n=37 500) from a representative panel of the Dutch adult population in which participants are asked about potential experiences of close relatives choosing for VSED or ILMC. A two-stage screening procedure will be used to determine whether the respondents' experiences represent a death by VSED or ILMC. Additional interviews (n=40) will be held with questionnaire respondents indicating their willingness to participate (May to September 2024). Quantitative data will be analysed using SPSS software, and qualitative data will be thematically analysed using NVivo software. ETHICS AND DISSEMINATION The study obtained approval from the Medical Research Ethics Committee of the Erasmus Medical Center, under number MEC-2023-0689. Informed consent will be sought from study participants in line with General Data Protection Regulation legislation. Results of the study will be disseminated through publications in scientific journals and conference presentations. TRIAL REGISTRATION NUMBER NCT06186791.
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Affiliation(s)
- Fenne Bosma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Arianne Stoppelenburg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Suzanne van de Vathorst
- Department of Medical Ethics, Philosophy, and History of Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
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Trejo-Gabriel-Galán JM. Euthanasia and assisted suicide in neurological diseases: a systematic review. Neurologia 2024; 39:170-177. [PMID: 38272260 DOI: 10.1016/j.nrleng.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/29/2021] [Accepted: 04/04/2021] [Indexed: 01/27/2024] Open
Abstract
OBJECTIVE To identify the neurological diseases for which euthanasia and assisted suicide are most frequently requested in the countries where these medical procedures are legal and the specific characteristics of euthanasia in some of these diseases, and to show the evolution of euthanasia figures. METHODS We conducted a systematic literature review. RESULTS Dementia, motor neuron disease, multiple sclerosis, and Parkinson's disease are the neurological diseases that most frequently motivate requests for euthanasia or assisted suicide. Requests related to dementia constitute the largest group, are growing, and raise additional ethical and legal issues due to these patients' diminished decision-making capacity. In some countries, the ratios of euthanasia requests to all cases of multiple sclerosis, motor neuron disease, or Huntington disease are higher than for any other disease. CONCLUSIONS After cancer, neurological diseases are the most frequent reason for requesting euthanasia or assisted suicide.
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Philip J, Le B, La Brooy C, Olver I, Kerridge I, Komesaroff P. Voluntary Assisted Dying/Euthanasia: Will This Have an Impact on Cancer Care in Future Years? Curr Treat Options Oncol 2023; 24:1351-1364. [PMID: 37535255 PMCID: PMC10547610 DOI: 10.1007/s11864-023-01126-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 08/04/2023]
Abstract
OPINION STATEMENT In considering the impact of medically hastened death (MHD) on cancer care, a wide range of variables needs to be considered including demographic factors, diagnoses, local cultural factors, and the legislative frameworks in place. Here, we present a synthesis of recently available published literature and empirical data collected following legislative change to enable MHD in Victoria, Australia to explore in detail the potential impact of MHD on cancer care with a focus on patients/families and professional groups. Our findings reveal that for patients and families, both physical and existential distress frequently underlie MHD requests, with the latter less readily recognised by health professionals. The responses of those around the patient making the request may have a very significant impact on relationships within families and upon the nature of the subsequent bereavement. For palliative care, while differing views may remain, it appears that there has been some accommodation of MHD into or alongside practice over time. The recognition of a shared commitment to relief of suffering of palliative care and MHD appears a helpful means of establishing how these practices may co-exist. In cancer practice more broadly, as individual professionals reflect upon their own roles, new relationships and pathways of patient movement (or referral) must be established in response to patients' requests. Our findings also highlight many unanswered questions in understanding the impact of MHD, including that upon those dying who choose not to access MHD, First Nations peoples, the participating health professionals' longer term, and the relief of suffering itself. A systematic approach to the evaluation of MHD legislation must be adopted in order to understand its full impact. Only then could it be determined if the aspirations for such legislative change were being met.
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Affiliation(s)
- Jennifer Philip
- Department of Medicine, University of Melbourne, Victoria Pde, Fitzroy 3065, Melbourne, Victoria, Australia.
- Palliative Care Service, St Vincent's Hospital, Melbourne, Victoria, Australia.
- Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre & Royal Melbourne Hospital, Melbourne, Victoria, Australia.
| | - Brian Le
- Department of Medicine, University of Melbourne, Victoria Pde, Fitzroy 3065, Melbourne, Victoria, Australia
- Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre & Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Camille La Brooy
- Public Health & Preventive Medicine, Monash University, Monash, Victoria, Australia
| | - Ian Olver
- University of Notre Dame of Australia, Sydney, NSW, Australia
| | - Ian Kerridge
- Haematology Department, Royal North Shore Hospital, St Leonards, NSW, Australia
- Sydney Health Ethics, University of Sydney, Sydney, NSW, Australia
- Department of Philosophy, Macquarie University, Macquarie, NSW, Australia
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Henry M, Alias A, Bisson-Gervais V, Liu JY, Dargis L, Gauthier L, Tapp D, Greenfield B, Mishara B. Medical assistance in dying in Canada: A scoping review on the concept of suffering. Psychooncology 2023; 32:1339-1347. [PMID: 37496186 DOI: 10.1002/pon.6196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 06/30/2023] [Accepted: 07/17/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVES Medical Assistance in Dying (MAiD) has been legal in Canada since June 2016. A person can receive MAiD if their suffering cannot be relieved under conditions that they consider acceptable. Informed consent requires that the person requesting MAiD has received all the information needed to make their decision; that is, medical diagnosis and prognosis, available treatments including palliative care. The evaluation of unbearable suffering is known to be challenging as suffering is often psychological, existential, and social in nature. While interventions to relieve suffering exist, it is unclear how suffering is assessed and addressed in the literature on MAiD practice. No scoping review exists on the topic in Canada. The aim of this study was to understand how the concept of suffering was approached within the Canadian MAiD grey (GL) and scientific (peer-reviewed) literature (SL), specifically: 1- How suffering is defined and assessed in the context of MAiD in Canada and 2- Which interventions in response to suffering are recommended within the process of obtaining informed consent for MAiD and throughout the process of MAiD itself. METHODS A scoping review was conducted based on PRISMA-SR guidelines. SL articles (N = 1027) were identified from a review of 6 databases and GL documents (N = 537) were obtained from the provinces of Quebec, Ontario and British Columbia. Documents were analyzed using NVivo with coding by two-raters and continuous team discussions. RESULTS A multidimensional definition of suffering, akin to the concept of total pain, is used. The assessment of suffering is based upon patients' reports. Tools to aid in the assessment are not comprehensively covered. Specific interventions to address suffering were often focused on active listening and the management of physical symptoms. No specific interventions were mentioned and there was no reference to clinical practice guidelines in the grey literature to address other components of suffering. The use of a multidisciplinary approach is suggested without specifying the nature of involvement. CONCLUSIONS Our review indicates that published guidelines of MAID assessments could include clearer structure around the assessment and management of suffering, with suggestions of tools that may help clarify types of suffering and reference to clinical practice guidelines and interventions to holistically attend to patient suffering with an attention on non-physical symptoms. Guidelines would benefit from clearer explanations of how members of an interdisciplinary teams could be coherently coordinated.
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Affiliation(s)
- Melissa Henry
- McGill University, Montreal, Quebec, Canada
- Lady-Davis Institute for Medical Research, Montreal, Quebec, Canada
- Jewish General Hospital, Montreal, Quebec, Canada
| | - Ali Alias
- McGill University, Montreal, Quebec, Canada
| | | | | | - Luc Dargis
- Université du Quebec à Montreal, Montreal, Quebec, Canada
| | | | - Diane Tapp
- Université Laval, Quebec City, Quebec, Canada
| | - Brian Greenfield
- McGill University, Montreal, Quebec, Canada
- Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Brian Mishara
- Université du Quebec à Montreal, Montreal, Quebec, Canada
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de Araújo AFM. Letter to the Editor: Castling Against Death: A Chess-Based Insight into the Paradox of Physician-Assisted Suicide. J Palliat Med 2023; 26:892. [PMID: 37428969 DOI: 10.1089/jpm.2023.0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Affiliation(s)
- Antonio Fábio Medrado de Araújo
- Postgraduate Programme in Medicine and Health (PPGMS), Federal University of Bahia (UFBA) and Expert of the Global Ethics Observatory (GEObs)-UNESCO, Salvador, Brazil
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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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Quah ELY, Chua KZY, Lua JK, Wan DWJ, Chong CS, Lim YX, Krishna L. A Systematic Review of Stakeholder Perspectives of Dignity and Assisted Dying. J Pain Symptom Manage 2023; 65:e123-e136. [PMID: 36244639 DOI: 10.1016/j.jpainsymman.2022.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/21/2022] [Accepted: 10/06/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The debate on assisted dying and its components, euthanasia and physician-assisted suicide has evolved with the emergence of the right to dignity and the wish to hasten death (WTHD). Whilst shaped by local legal and sociocultural considerations, appreciation of how patients, healthcare professionals and lawmakers relate notions of dignity to self-concepts of personhood and the desire for assisted dying will better inform and direct support of patients. METHODS Guided by the Systematic Evidence Based Approach, a systematic scoping review (SSR in SEBA) on perspectives of dignity, WTHD and personhood featured in PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Scopus databases and four key Palliative Care journals was conducted. The review hinged on the following questions: "what is the relationship between dignity and the wish to hasten death (WTHD) in the assisted dying debate?", "how is dignity conceptualised by patients with WTHD?" and "what are prevailing perspectives on the role of assisted dying in maintaining a dying patient's dignity?" RESULTS 6947 abstracts were identified, 663 full text articles reviewed, and 88 articles included. The four domains identified include 1) concepts of dignity through the lens of the Ring Theory of Personhood (RToP) including their various definitions and descriptions; 2) the relationship between dignity, WTHD and assisted dying with loss of dignity and autonomy foregrounded; 3) stakeholder perspectives for and against assisted dying including those of patient, healthcare provider and lawmaker; and 4) other dignity-conserving measures as alternatives to assisted dying. CONCLUSION Concepts of dignity constantly evolve throughout the patient's end of life journey. Understanding when and how these concepts of personhood change and trigger the fear of a loss of dignity or intractable suffering could direct timely, individualised and appropriate person-centred dignity conserving measures. We believe an RToP-based tool could fulfil this role and further study into the design of this tool is planned.
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Affiliation(s)
- Elaine Li Ying Quah
- Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
| | - Keith Zi Yuan Chua
- Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
| | - Jun Kiat Lua
- Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
| | - Darius Wei Jun Wan
- Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
| | - Chi Sum Chong
- Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
| | - Yun Xue Lim
- Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
| | - Lalit Krishna
- Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore; Division of Cancer Education (L.K), National Cancer Centre Singapore Singapore; Division of Supportive and Palliative Care (L.K), National Cancer Centre Singapore (L.K), Singapore; Palliative Care Institute Liverpool (L.K), Cancer Research Centre, University of Liverpool, Liverpool, United Kingdom; Health Data Science (L.K), Liverpool; Duke-NUS Medical School (L.K), Singapore; Centre of Biomedical Ethics (L.K), Singapore; PalC (L.K), The Palliative Care Centre for Excellence in Research and Education, Dover Park Hospice, Singapore.
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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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Cheng EY, Mah K, Al-Awamer A, Pope A, Swami N, Wong JL, Mathews J, Howell D, Hannon B, Rodin G, Shapiro GK, Li M, Le LW, Zimmermann C. Public interest in medical assistance in dying and palliative care. BMJ Support Palliat Care 2022; 12:448-456. [PMID: 36171108 DOI: 10.1136/spcare-2022-003910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/13/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Medical assistance in dying (MAiD) is legal in an increasing number of countries, but there are concerns that its availability may compromise access to palliative care. We assessed public interest in MAiD, palliative care, both, or neither, and examined characteristics associated with this interest. METHODS We surveyed a representative sample of the adult Canadian public, accessed through a panel from May to June 2019. Weighted generalised multinomial logistic regression analyses were used to determine characteristics associated with interest in referral to palliative care, MAiD, or both, in the event of diagnosis with a serious illness. RESULTS Of 1362 participants who had heard of palliative care, 611 (44.8% weighted (95% CI 42.1% to 47.5%)) would be interested in both MAiD and palliative care, 322 (23.9% (95% CI 21.5% to 26.2%)) palliative care alone, 171 (12.3% (95% CI 10.5% to 14.1%)) MAiD alone and 258 (19.0% (95% CI 16.9% to 21.2%)) neither. In weighted multinomial logistic regression analyses, interest in both MAiD and palliative care (compared with neither) was associated with better knowledge of the definition of palliative care, older age, female gender, higher education and less religiosity; interest in palliative care alone was associated with better knowledge of the definition of palliative care, older age, female gender and being married/common law; interest in MAiD alone was associated with less religiosity (all p<0.05). CONCLUSIONS There is substantial public interest in potential referral to both MAiD and palliative care. Simultaneous availability of palliative care should be ensured in jurisdictions where MAiD is legal, and education about palliative care should be a public health priority.
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Affiliation(s)
- Emily YiQin Cheng
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Kenneth Mah
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ahmed Al-Awamer
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ashley Pope
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Nadia Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Joanne L Wong
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jean Mathews
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Palliative Medicine, Departments of Medicine and Oncology, Queen's University, Kingston, Ontario, Canada
| | - Doris Howell
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Gilla K Shapiro
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Madeline Li
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Lisa W Le
- Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Dombrecht L, Beernaert K, Chambaere K, Cools F, Goossens L, Naulaers G, Cohen J, Deliens L. End-of-life decisions in neonates and infants: a population-level mortality follow-back study. Arch Dis Child Fetal Neonatal Ed 2022; 107:340-341. [PMID: 34131039 DOI: 10.1136/archdischild-2021-322108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Laure Dombrecht
- End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Ghent, Belgium .,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | | | - Linde Goossens
- Department of Neonatology, University Hospital Ghent, Ghent, Belgium
| | | | - Joachim Cohen
- End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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Dombrecht L, Beernaert K, Chambaere K, Cools F, Goossens L, Naulaers G, Cornette L, Laroche S, Theyskens C, Vandeputte C, Van de Broek H, Cohen J, Deliens L. End-of-life decisions in neonates and infants: a nationwide mortality follow-back survey. BMJ Support Palliat Care 2022:bmjspcare-2021-003357. [PMID: 35459686 DOI: 10.1136/bmjspcare-2021-003357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/12/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Neonatology has undergone important clinical and legal changes; however, the implications for end-of-life decision-making in seriously ill neonates to date are unknown. Our aim was to examine changes in prevalence and characteristics of end-of-life decisions (ELDs) in neonatology. METHODS We performed a nationwide mortality follow-back survey in August 1999 to July 2000 and September 2016 to December 2017 in Flanders, Belgium. Data were linked to information from death certificates. For each death under the age of 1, physicians were asked to complete an anonymous questionnaire about which ELDs were made preceding death. RESULTS The response rate was 87% in 1999-2000 (253/292) and 83% in 2016-2017 (229/276). The proportion of deaths of infants born before 26 weeks' gestation was increased (14% vs 34%, p=0.001). Prevalence of ELDs remained stable at 60%, with non-treatment decisions occurring in about 35% of all deaths. Use of medication with an explicit life-shortening intention was prevalent in 7%-10% of all deaths. In early neonatal death (<7 days old) medication with an explicit life-shortening intention decreased from 12% to 6%, in late neonatal death (7-27 days old), it increased from 0% to 26%, and in postneonatal death (>27 days old), it increased from 2% to 10%. CONCLUSIONS Over a timespan of 17 year, the prevalence of neonatal ELDs has remained stable. A substantial number of deaths was preceded by the intentionally hastening of death by administrating medication. While surveying solely the physician perspective in this paper, there is a need for an open multidisciplinary debate, including, for example, nursing staff and family members, based on clinical as well as ethical and jurisdictional reflections to discuss the need for international guidelines.
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Affiliation(s)
- Laure Dombrecht
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Brussel, Belgium
| | - Linde Goossens
- Department of Neonatology, University Hospital Ghent, Gent, Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Luc Cornette
- Department of Neonatology, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
| | - Sabrina Laroche
- Department of Neonatology, University Hospital Antwerp, Edegem, Belgium
| | - Claire Theyskens
- Department of Neonatology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | - Christine Vandeputte
- Department of Neonatology, GZA Ziekenhuizen Campus Sint-Augustinus, Wilrijk, Belgium
| | - Hilde Van de Broek
- Department of Neonatology, ZNA Middelheim, Antwerpen, Antwerpen, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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12
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Vincent JL, Creteur J. Appropriate care for the elderly in the ICU. J Intern Med 2022; 291:458-468. [PMID: 34487587 DOI: 10.1111/joim.13371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Life expectancy is rising worldwide and increasing numbers of elderly patients are being admitted to the intensive care unit (ICU). Because ageing is associated with changes in organ function, increased frailty, reduced activities of daily living, reduced mobility, and reduced cognition, elderly patients represent a particular subgroup of ICU patients. Ethical decisions related to the appropriateness of intensive care and/or life-sustaining interventions, the withdrawing and withholding of life support, and terminal sedation are more frequent in these patients and will be discussed in this review. Such decisions must be tailored to the individual to take into consideration personal beliefs and wishes.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
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13
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Voltz R, Boström K, Dojan T, Rosendahl C, Gehrke L, Shah-Hosseini K, Kremeike K. Is trained communication about desire to die harmful for patients receiving palliative care? A cohort study. Palliat Med 2022; 36:489-497. [PMID: 34937431 PMCID: PMC8972950 DOI: 10.1177/02692163211065671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Palliative patients frequently express a desire to die. Health professionals report uncertainty regarding potential risks of addressing it. AIM We aim to evaluate effects of desire to die-conversations on palliative patients. DESIGN Within a prospective mixed-methods cohort study, we trained health professionals in dealing with desire to die. Afterwards, they held conversations about it with patients. Effects on depressiveness, hopelessness, wish to hasten death, death anxiety, patient-health professional-relationship, and will to live were evaluated at baseline (t0), 1 (t1), and 6 weeks afterwards (t2). Results were analyzed descriptively. SETTING/PARTICIPANTS From April 2018 to March 2020, 43 health professionals asked 173 patients from all stationary and ambulatory palliative care settings (within 80 km radius) for participation. Complete assessments were obtained from n = 85 (t0), n = 64 (t1), and n = 46 (t2). RESULTS At t1, patients scored significantly lower on depressiveness (med = 8, M = 8.1, SD = 5.4) than at t0 (med = 9.5, M = 10.5, SD = 5.8) with Z = -3.220, p = 0.001 and Cohen's d = 0.42. This was due to medium-severely depressed patients: At t1, their depressiveness scores decreased significantly (med = 9, M = 9.8; SD = 5.1) compared to t0 (med = 14, M = 15.2; SD = 3.9) with Z = -3.730, p ⩽ 0.000 and Cohen's d = 1.2, but others' did not. All other outcomes showed positive descriptive trends. CONCLUSIONS Desire to die-conversations through trained health professionals do not harm palliative patients. Results cautiously suggest temporary improvement.
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Affiliation(s)
- Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Clinical Trials Center (ZKS), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.,Center for Health Services Research, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Kathleen Boström
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Thomas Dojan
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Carolin Rosendahl
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Leonie Gehrke
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Kija Shah-Hosseini
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Kerstin Kremeike
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
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14
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Borovecki A, Curkovic M, Nikodem K, Oreskovic S, Novak M, Rubic F, Vukovic J, Spoljar D, Gordijn B, Gastmans C. Attitudes about withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide, and physician assisted suicide: a cross-sectional survey among the general public in Croatia. BMC Med Ethics 2022; 23:13. [PMID: 35172812 PMCID: PMC8851732 DOI: 10.1186/s12910-022-00751-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 02/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying. METHODS A cross-sectional study was conducted on a three-stage random sample of adult citizens of the Republic of Croatia, stratified by regions, counties, and locations within those counties (N = 1203). In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis (component model, varimax rotation and GK dimensionality reduction criterion), correlation analysis (Bivariate correlation, Pearson's coefficient) and multiple regression analysis for data analysis. RESULTS 38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person's autonomous decisions regarding end-of-life procedures. CONCLUSIONS The study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people's views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia.
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Affiliation(s)
- Ana Borovecki
- School of Medicine, Center for Palliative Medicine, Medical Ethics and Communication Skills, University of Zagreb, Salata 2, 10000, Zagreb, Croatia.
| | - Marko Curkovic
- School of Medicine, University Psychiatric Hospital Vrapče, University of Zagreb, Zagreb, Croatia
| | - Krunoslav Nikodem
- Faculty of Humanities and Social Sciences, Department of Sociology, University of Zagreb, Zagreb, Croatia
| | - Stjepan Oreskovic
- School of Medicine, Department of Medical Sociology, University of Zagreb, Zagreb, Croatia
| | - Milivoj Novak
- School of Medicine, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Filip Rubic
- School of Medicine, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Jurica Vukovic
- School of Medicine, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Diana Spoljar
- School of Medicine, University Hospital Dubrava, University of Zagreb, Zagreb, Croatia
| | - Bert Gordijn
- Institute of Ethics, School of Theology, Philosophy, and Music, Dublin City University, Dublin, Ireland
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Leuven, Belgium
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15
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Velasco Bernal C, Trejo-Gabriel-Galan JM. [Euthanasia laws in Spain and in the world: Medical aspects]. Aten Primaria 2021; 54:102170. [PMID: 34798415 PMCID: PMC8605061 DOI: 10.1016/j.aprim.2021.102170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/04/2021] [Accepted: 07/05/2021] [Indexed: 11/17/2022] Open
Abstract
Objetivo Comparar la ley española de eutanasia y suicidio asistido con las que existen en otros países. Diseño Revisión sistemática de la bibliografía. Fuentes de datos Se buscaron en Medline/PubMed, EMBASE y Biblioteca Cochrane los estudios que contuvieran en su título o resumen los descriptores «eutanasia» o «suicidio asistido» y además «legislación» o «ley», entre 2002 y final de 2020. Selección de estudios La búsqueda encontró 1.647 estudios y tras su cribado se valoraron 663, de los cuales 30 se incluyeron en la revisión. Se rechazaron estudios en los que solo constaran opiniones o no aportaran datos sobre la eutanasia/suicidio asistido en los países que los tienen regulados. Extracción de datos Se registraron los criterios que regulan la aceptación o rechazo de una petición de eutanasia o suicidio asistido en España y en los demás países en que están despenalizados. Resultados Las regulaciones de la eutanasia en el mundo pueden agruparse en tres: leyes que permiten la eutanasia y el suicidio asistido (Países Bajos, Bélgica, Canadá, algunos estados de Australia, Nueva Zelanda, España), en las que la ley solo permite el suicidio asistido (EE. UU.) y en las que se admite únicamente el suicidio asistido y en base a sentencias judiciales, sin legislación específica (Suiza, Alemania). Conclusiones Aunque hay diferencias, las leyes a las que más se asemeja la ley española de eutanasia son las de Países Bajos y Bélgica, por lo que es previsible que la casuística de eutanasia y sus cifras en España se parezcan en el futuro a las de estos países.
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16
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Clarke C, Cannon M, Skokauskas N, Twomey P. The debate about physician assisted suicide and euthanasia in Ireland - Implications for psychiatry. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2021; 79:101747. [PMID: 34689096 DOI: 10.1016/j.ijlp.2021.101747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/03/2021] [Accepted: 10/10/2021] [Indexed: 06/13/2023]
Abstract
At present, Physician-Assisted Suicide and Euthanasia are illegal in Ireland, and are forbidden under the Irish Medical Council's ethical guidelines. With the recent introduction of a Bill in the Irish Dáil (Parliament) which would have permitted Physicial-Assisted Suicide in that country, Physician-Assisted Suicide and Euthanasia (PAS-E) has become the subject of debate, both within the medical profession and in the wider community. Geographical and historical considerations mean that the Irish situation may have relevance to many other countries, which have apparently little similarity among themselves. PAS-E is becoming more widespread and more acceptable in many countries throughout the world. There are ramifications for many aspects of medical care, and matters such as the broadening of euthanasia criteria beyond terminal illness, attitudes toward suicide, and the determination of capacity and voluntariness, suggest that it will be an important issue, not only for psychiatrists, but for the wider medical community as well, in the coming years.
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Affiliation(s)
- Ciaran Clarke
- University College Dublin Health Sciences Centre, Dublin D04 C7X2, Ireland.
| | - Mary Cannon
- Royal College of Surgeons in Ireland, Dept of Psychiatry, Education and Research Centre, Beaumont Hospital, Dublin D09 V2N0, Ireland.
| | - Norbertas Skokauskas
- NTNU Regional Centre for Child and Youth Mental Health and Child Welfare, Faculty of Medicine and Health Sciences, Trondheim, Norway.
| | - Pauline Twomey
- Health Service Executive, Phoenix Care Centre, Grangegorman Campus, North Circular Road, Dublin 7 D07 VPT0, Ireland.
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17
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Monedero P. Euthanasia is not medicine. BMJ Support Palliat Care 2021; 12:198. [PMID: 34373281 DOI: 10.1136/bmjspcare-2021-003294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 07/24/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Pablo Monedero
- Anaesthesia and Intensive Care, University of Navarra, Pamplona, Spain
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18
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White BP, Willmott L. Evidence-based law making on voluntary assisted dying. AUST HEALTH REV 2021; 44:544-546. [PMID: 31778640 DOI: 10.1071/ah19201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/19/2019] [Indexed: 11/23/2022]
Abstract
Voluntary assisted dying is a major social policy issue with significant implications for the health system, health and medical professionals and the wider community. Voluntary assisted dying is now lawful in Victoria in limited circumstances, and other states are likely to follow Victoria and legalise the practice. In the same way that we expect the making of health policy and the provision of health care to be evidence based, so too should we should expect evidence-based law making from our parliamentarians on this important topic.
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Affiliation(s)
- Ben P White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, GPO Box 2434, Brisbane, Qld 4001, Australia. ; and Corresponding author.
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, GPO Box 2434, Brisbane, Qld 4001, Australia.
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19
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Trejo-Gabriel-Galán JM. Euthanasia and assisted suicide in neurological diseases: a systematic review. Neurologia 2021; 39:S0213-4853(21)00090-6. [PMID: 34090721 DOI: 10.1016/j.nrl.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/29/2021] [Accepted: 04/04/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To identify the neurological diseases for which euthanasia and assisted suicide are most frequently requested in the countries where these medical procedures are legal and the specific characteristics of euthanasia in some of these diseases, and to show the evolution of euthanasia figures. METHODS We conducted a systematic literature review. RESULTS Dementia, motor neuron disease, multiple sclerosis, and Parkinson's disease are the neurological diseases that most frequently motivate requests for euthanasia or assisted suicide. Claims related to dementia constitute the largest group, are growing, and raise additional ethical and legal issues due to these patients' diminished decision-making capacity. In some countries, the ratios of euthanasia requests to all cases of multiple sclerosis, motor neuron disease, or Huntington disease are higher than for any other disease. CONCLUSIONS After cancer, neurological diseases are the most frequent reason for requesting euthanasia or assisted suicide.
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20
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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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21
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Raus K, Vanderhaegen B, Sterckx S. Euthanasia in Belgium: Shortcomings of the Law and Its Application and of the Monitoring of Practice. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2021; 46:80-107. [PMID: 33491735 DOI: 10.1093/jmp/jhaa031] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In 2002 with the passing of the Euthanasia Law, Belgium became one of the few countries worldwide to legalize euthanasia. In the 18 years since the passing of the law, much has changed. We argue that in Belgium a widening of the use of euthanasia is occurring and that this can be ethically and legally problematic. This is in part related to the fact that several legal requirements intended to operate as safeguards and procedural guarantees in reality often fail to operate as such. We focus on three kinds of safeguards or procedural guarantees: (1) the legally defined due care criteria for eligibility for euthanasia; (2) the consultation of a second (and sometimes third) physician; and (3) the reporting of euthanasia cases to the Federal Control and Evaluation Commission for Euthanasia. We will show how each of these three safeguards can exhibit shortcomings in theory and practice.
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22
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Aznar J. "Death by Donation": Harvesting Organs from Still-Living Persons. LINACRE QUARTERLY 2020; 87:372-373. [PMID: 33100383 DOI: 10.1177/0024363920944841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Justo Aznar
- Institute of Life Sciences, Catholic University of Valencia, Spain
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23
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Chandhoke G, Pond G, Levine O, Oczkowski S. Oncologists and medical assistance in dying: where do we stand? Results of a national survey of Canadian oncologists. Curr Oncol 2020; 27:263-269. [PMID: 33173378 PMCID: PMC7606035 DOI: 10.3747/co.27.6295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background In June 2016, when the Parliament of Canada passed Bill C-14, the country joined the small number of jurisdictions that have legalized medical assistance in dying (maid). Since legalization, nearly 7000 Canadians have received maid, most of whom (65%) had an underlying diagnosis of cancer. Although Bill C-14 specifies the need for government oversight and monitoring of maid, the government-collected data to date have tracked patient characteristics, rather than clinician encounters and beliefs. We aimed to understand the views of Canadian oncologists 2 years after the legalization of maid. Methods We developed and administered an online survey to medical and radiation oncologists to understand their exposure to maid, self-perceived knowledge, willingness to participate, and perception of the role of oncologists in introducing maid as an end-of-life care option. We used complete sampling through the Canadian Association of Medical Oncologists and the Canadian Association of Radiation Oncology membership e-mail lists. The survey was sent to 691 physicians: 366 radiation oncologists and 325 medical oncologists. Data were collected during March-June 2018. Results are presented using descriptive statistics and univariate or multivariate analysis. Results The survey attracted 224 responses (response rate: 32.4%). Of the responding oncologists, 70% have been approached by patients requesting maid. Oncologists were of mixed confidence in their knowledge of the eligibility criteria. Oncologists were most willing to engage in maid with an assessment for eligibility, and yet most refer to specialized teams for assessments. In terms of introducing maid as an end-of-life option, slightly more than half the responding physicians (52.8%) would initiate a conversation about maid with a patient under certain circumstances, most commonly the absence of viable therapeutic options, coupled with unmanageable patient distress. Conclusions In this first national survey of Canadian oncologists about maid, we found that most respondents encounter patient requests for maid, are confident in their knowledge about eligibility, and are willing to act as assessors of eligibility. Many oncologists believe that, under some circumstances, it is appropriate to present maid as a therapeutic option at the end of life. That finding warrants further deliberation by national or regional bodies for the development of consensus guidelines to ensure equitable access to maid for patients who wish to pursue it.
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Affiliation(s)
- G Chandhoke
- Department of Oncology, R.S. McLaughlin Durham Regional Cancer Centre, Oshawa
- Department of Oncology, Juravinski Cancer Centre, Hamilton
| | - G Pond
- Department of Oncology, R.S. McLaughlin Durham Regional Cancer Centre, Oshawa
| | - O Levine
- Department of Oncology, R.S. McLaughlin Durham Regional Cancer Centre, Oshawa
| | - S Oczkowski
- Department of Medicine, Division of Critical Care, Hamilton Health Sciences, Hamilton, ON
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Khan MZ, Khan MU, Munir MB. Trends and Disparities in Palliative Care Encounters in Acute Heart Failure Admissions; Insight From National Inpatient Sample. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 23:52-56. [PMID: 32861636 DOI: 10.1016/j.carrev.2020.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/25/2020] [Accepted: 08/12/2020] [Indexed: 12/17/2022]
Abstract
Heart failure is a leading cause of readmissions in the United States, although treatment has come along away, palliative care is often not appropriately offered in advanced heart failure. The purpose of this study was to use a large database of national in-patient sample to find out the use of palliative care in acute heart failure admissions. Data from 2002 to 2017 was used for analysis. Simple linear regression was used for trend analysis over the years. Variables that were statistically significant in univariate analysis were used in single-step (entry method) multiple logistic analysis. The use of palliative care was found to be low at 4.1%, although recent trends have shown an increase (from 0.4% in 2002 to 6.2% in 2017). Women (0.3% in 2002 to 6.5% in 2017) and Caucasians (0.6% in 2002 to 6.9% in 2017) had a higher proportion of PC encounters as compared to men (0.5% in 2002 to 5.9% in 2017) and other racial minorities, increasing age (OR, 1.04[CI; 1.03-1.04], p < 0.01), female gender (OR, 1.03[CI; 1.02-1.03], p < 0.01), do not resuscitate status (OR, 10.62[CI; 10.53-10.70], p < 0.01), diabetes mellitus (OR, 1.10[CI; 1.01-1.11], p < 0.01), liver disease (OR, 1.63[CI; 1.60-1.66], p < 0.01), renal failure (OR, 1.40[CI; 1.39-1.41], p < 0.01), acute myocardial infarction (OR, 1.28[CI; 1.27-1.30], p < 0.01), and cardiogenic shock (OR, 2.89[CI; 2.84-2.93], p < 0.01) were associated with higher odds of having PC encounter. In conclusion, the use of palliative care has increased in the United States over the years, however, it is still low as compared to other high-income countries.
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Affiliation(s)
- Muhammad Zia Khan
- Department of Medicine, West Virginia University, Morgantown, WV, USA.
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25
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Six S, Van Overmeire R, Bilsen J, Laureys S, Poelaert J, Theuns P, Deschepper R. Attitudes of Professional Caregivers and Family Members Regarding the Use of Monitoring Devices to Improve Assessments of Pain and Discomfort During Continuous Sedation Until Death. J Pain Symptom Manage 2020; 60:390-399. [PMID: 32105791 DOI: 10.1016/j.jpainsymman.2020.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/14/2020] [Accepted: 02/14/2020] [Indexed: 12/31/2022]
Abstract
CONTEXT Assessing consciousness and pain during continuous sedation until death (CSD) by behavior-based observational scales alone has recently been put into question. Instead, the use of monitoring technology has been suggested to make more objective and reliable assessments. Insights into which factors influence attitudes toward using these monitoring devices in a context of CSD is a first step in formulating recommendations to inform future practice. OBJECTIVES The aim of this study was to find out what influences professional caregivers' and family members' (FMs) attitudes regarding the use of monitors during CSD. METHODS We conducted semistructured face-to-face interviews with 20 professional caregivers and 15 FMs, who cared for a patient or had an FM, respectively, who took part in a study using monitoring devices. Recruitment took place in an academic hospital, a locoregional hospital, and two nursing homes, all located in Belgium. Two researchers independently analyzed the data, using grounded theory to inductively develop a model that represents the emerging attitude toward use of monitors during CSD. RESULTS Our model shows that the emerging attitudes toward using monitors during CSD is determined by view on CSD, desire for peace of mind, emotional valence attached to using monitors, and the realization that the sole use of behavior-based observational measures could be unreliable in a CSD context. We identified several facilitators and barriers to inform future implementation strategies. CONCLUSION Most participants had no objections, and all participants found the use of monitoring devices during CSD feasible and acceptable. We identified a number of facilitators and barriers and suggested that being aware that care can be improved, good communication, shared decision making, and continuing professional education can overcome the identified barriers. We suggest future research would focus on developing implementation strategies and guidelines for introducing objective monitoring devices in diverse palliative care settings.
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Affiliation(s)
- Stefaan Six
- Department of Public Health, Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium; Cyclotron Research Centre and Neurology Department, Coma Science Group, University and University Hospital of Liège, Liège, Belgium.
| | - Roel Van Overmeire
- Department of Public Health, Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium
| | - Johan Bilsen
- Department of Public Health, Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium
| | - Steven Laureys
- Cyclotron Research Centre and Neurology Department, Coma Science Group, University and University Hospital of Liège, Liège, Belgium
| | - Jan Poelaert
- Department of Anesthesiology & Perioperative Medicine, Vrije Universiteit Brussel, Brussel, Belgium
| | - Peter Theuns
- Department of Public Health, Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium
| | - Reginald Deschepper
- Department of Public Health, Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium
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Counting Cases of Termination of Life without Request: New Dances with Data. Camb Q Healthc Ethics 2020; 29:395-402. [PMID: 32484146 DOI: 10.1017/s0963180120000122] [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: 11/07/2022]
Abstract
This paper explores the common argument proposed by opponents of the legalization of euthanasia that permitting ending a patient's life at their request will lead to the eventual legalization of terminating life without request. The author's examination of data does not support the conclusion that a causal connection exists between legalizing ending of life on request and an increase in the number of cases without request.
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Somerville M. Does It Matter How We Die? Ethical and Legal Issues Raised by Combining Euthanasia and Organ Transplantation. LINACRE QUARTERLY 2020; 86:359-365. [PMID: 32431428 DOI: 10.1177/0024363919872623] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
If, in jurisdictions with legalized euthanasia, obtaining organs for transplant from euthanized people is allowed, must their organs be taken only after death or should euthanasia be allowed to be performed by removal of vital organs? Asked another way, if "Donation after Death" is practiced, why not "Death by Donation?" The article addresses two questions. First, "What issues does connecting euthanasia and organ donation raise?" They include dealing with uncertainty regarding the definition of death, defining what constitutes conscientiously objecting healthcare professionals' involvement in euthanasia, and whether connecting euthanasia and transplantation makes conflicts of interest for healthcare professionals unavoidable. Additional issues raised by death by donation include breach of the "dead-donor rule"; what would constitute informed consent to it; and what impact its acceptance would have on important foundational societal values, especially respect for human dignity and human life. The second question is "Why might some people who agree with euthanasia and even organ donation after death by euthanasia find death by donation ethically unacceptable?" Considerations again include its harmful impact on upholding respect for human dignity and human life and that the "wisdom of repugnance" could be informing these people's reaction. It is concluded that in order to avoid serious breaches of ethics, organ transplantation and euthanasia should not be linked in any way.
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Affiliation(s)
- Margaret Somerville
- School of Medicine, Institute for Ethics & Society, University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
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Downar J, Fowler RA, Halko R, Huyer LD, Hill AD, Gibson JL. Early experience with medical assistance in dying in Ontario, Canada: a cohort study. CMAJ 2020; 192:E173-E181. [PMID: 32051130 DOI: 10.1503/cmaj.200016] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Medical assistance in dying (MAiD) was legalized across Canada in June 2016. Some have expressed concern that patient requests for MAiD might be driven by poor access to palliative care and that social and economic vulnerability of patients may influence access to or receipt of MAiD. To examine these concerns, we describe Ontario's early experience with MAiD and compare MAiD decedents with the general population of decedents in Ontario. METHODS We conducted a retrospective cohort study comparing all MAiD-related deaths with all deaths in Ontario, Canada, between June 7, 2016, and Oct. 31, 2018. Clinical and demographic characteristics were collected for all MAiD decedents and compared with those of all Ontario decedents when possible. We used logistic regression analyses to describe the association of demographic and clinical factors with receipt of MAiD. RESULTS A total of 2241 patients (50.2% women) were included in the MAiD cohort, and 186 814 in the general Ontario decedent cohort. Recipients of MAiD reported both physical (99.5%) and psychologic suffering (96.4%) before the procedure. In 74.4% of cases, palliative care providers were involved in the patient's care at the time of the MAiD request. The statutory 10-day reflection period was shortened for 26.6% of people. Compared with all Ontario decedents, MAiD recipients were younger (mean 74.4 v. 77.0 yr, standardized difference 0.18);, more likely to be from a higher income quintile (24.9% v. 15.6%, standardized difference across quintiles 0.31); less likely to reside in an institution (6.3% v. 28.0%, standardized difference 0.6); more likely to be married (48.5% v. 40.6%) and less likely to be widowed (25.7% v. 35.8%, standardized difference 0.34); and more likely to have a cancer diagnosis (64.4% v. 27.6%, standardized difference 0.88 for diagnoses comparisons). INTERPRETATION Recipients of MAiD were younger, had higher income, were substantially less likely to reside in an institution and were more likely to be married than decedents from the general population, suggesting that MAiD is unlikely to be driven by social or economic vulnerability. Given the high prevalence of physical and psychologic suffering, despite involvement of palliative care providers in caring for patients who request MAiD, future studies should aim to improve our understanding and treatment of the specific types of suffering that lead to a MAiD request.
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Affiliation(s)
- James Downar
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont
| | - Robert A Fowler
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont
| | - Roxanne Halko
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont
| | - Larkin Davenport Huyer
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont
| | - Andrea D Hill
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont
| | - Jennifer L Gibson
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.
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Scurria S, Asmundo A, Gualniera P. Euthanasia and physician-assisted suicide: what about in Europe? GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2020. [DOI: 10.23736/s0393-3660.19.04076-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ely EW, Azoulay E, Sprung CL. Distinction between good palliative care and intending death. Intensive Care Med 2019; 46:147-148. [PMID: 31659385 PMCID: PMC7223510 DOI: 10.1007/s00134-019-05827-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2019] [Indexed: 11/25/2022]
Affiliation(s)
- E Wesley Ely
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (VA GRECC), Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Elie Azoulay
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (VA GRECC), Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Charlie L Sprung
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (VA GRECC), Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
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Calkins BC, Swetz KM. Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Imperative Over a Crisis. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:68-70. [PMID: 31566498 DOI: 10.1080/15265161.2019.1653398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Bethany C Calkins
- Jacobs School of Medicine and Veteran Affairs Western New York Healthcare System
| | - Keith M Swetz
- UAB Medicine Supportive Care and Survivorship Clinic, UAB Center for Palliative and Supportive Care, University of Alabama School of Medicine and UAB Medicine and Birmingham VAMC
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Ely EW. Death by organ donation: euthanizing patients for their organs gains frightening traction. Intensive Care Med 2019; 45:1309-1311. [PMID: 31444501 DOI: 10.1007/s00134-019-05702-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/17/2019] [Indexed: 11/24/2022]
Affiliation(s)
- E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, VA Geriatric Research Education and Clinical Center (GRECC), Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN, USA.
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Bos DC, de Graaf E, de Graeff A, Teunissen SCCM. Determinants of unbearable suffering in hospice patients who died due to Euthanasia: A retrospective cohort study. DEATH STUDIES 2019; 45:451-458. [PMID: 31390320 DOI: 10.1080/07481187.2019.1648338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In this retrospective study, determinants of unbearable suffering in hospice patients who died due to euthanasia were analyzed. The four dimensions of suffering (physical, psychological, social, and existential) were used as a framework. 28 patients (5% of all admitted patients in nine years) were included. Most patients indicated 3-5 determinants, predominantly a combination of physical (96% of patients) and existential determinants (89%). Fatigue, anorexia, and dry mouth were the most prevalent and severe symptoms. Psychological (21%) and social determinants (4%) were much less often described. The results of this study may be used to assess determinants playing a role in euthanasia requests.
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Affiliation(s)
- Dieuwke C Bos
- Department of Medical Oncology, Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Everlien de Graaf
- Center of Expertise in Palliative Care, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexander de Graeff
- Department of Medical Oncology, Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Academic Hospice Demeter, De Bilt, The Netherlands
| | - Saskia C C M Teunissen
- Center of Expertise in Palliative Care, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Academic Hospice Demeter, De Bilt, The Netherlands
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Affiliation(s)
- Daniel P Sulmasy
- The Kennedy Institute of Ethics, Departments of Medicine and Philosophy, Georgetown University, Washington, DC
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35
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Dierickx S, Onwuteaka-Philipsen B, Penders Y, Cohen J, van der Heide A, Puhan MA, Ziegler S, Bosshard G, Deliens L, Chambaere K. Commonalities and differences in legal euthanasia and physician-assisted suicide in three countries: a population-level comparison. Int J Public Health 2019; 65:65-73. [DOI: 10.1007/s00038-019-01281-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/12/2019] [Accepted: 06/28/2019] [Indexed: 01/22/2023] Open
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Potter J. The psychological slippery slope from physician-assisted death to active euthanasia: a paragon of fallacious reasoning. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2019; 22:239-244. [PMID: 30145689 DOI: 10.1007/s11019-018-9864-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In the debate surrounding the morality and legality of the practices of physician-assisted death and euthanasia, a common logical argument regularly employed against these practices is the "slippery slope argument." One formulation of this argument claims that acceptance of physician-assisted death will eventually lead down a "slippery slope" into acceptance of active euthanasia, including its voluntary, non-voluntary, and/or involuntary forms, through psychological and social processes that warp a society's values and moral perspective of a practice over an extended period of time. This formulation is known as the psychological slippery slope argument. This paper analyzes the psychological slippery slope argument as it is applied to the practice of physician-assisted death, and utilizing recent empirical evidence from various nations around the world that practice physician-assisted death and/or euthanasia, the paper argues that (1) employing the psychological slippery slope argument against physician-assisted death is logically fallacious, (2) this kind of slippery slope is unfounded in practice, and thus (3) the psychological slippery slope argument is insufficient on its own to justify continued legal prohibition of physician-assisted death.
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Affiliation(s)
- Jordan Potter
- Cleveland Clinic, Center for Bioethics, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Wendrich-van Dael AE, Pivodic L, Cohen J, Deliens L, Van den Block L, Chambaere K. End-of-Life Decision Making for People Who Died of Dementia: A Mortality Follow-Back Study Comparing 1998, 2007, and 2013 in Flanders, Belgium. J Am Med Dir Assoc 2019; 20:1347-1349. [PMID: 31147288 DOI: 10.1016/j.jamda.2019.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/05/2019] [Accepted: 04/07/2019] [Indexed: 11/30/2022]
Affiliation(s)
| | - Lara Pivodic
- End-of-Life Care Research Group Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
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Verhofstadt M, Van Assche K, Sterckx S, Audenaert K, Chambaere K. Psychiatric patients requesting euthanasia: Guidelines for sound clinical and ethical decision making. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 64:150-161. [PMID: 31122625 DOI: 10.1016/j.ijlp.2019.04.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/28/2019] [Accepted: 04/03/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Since Belgium legalised euthanasia, the number of performed euthanasia cases for psychological suffering in psychiatric patients has significantly increased, as well as the number of media reports on controversial cases. This has prompted several healthcare organisations and committees to develop policies on the management of these requests. METHOD Five recent initiatives that offer guidance on euthanasia requests by psychiatric patients in Flanders were analysed: the protocol of Ghent University Hospital and advisory texts of the Flemish Federation of Psychiatry, the Brothers of Charity, the Belgian Advisory Committee on Bioethics, and Zorgnet-Icuro. These were examined via critical point-by-point reflection, focusing on all legal due care criteria in order to identify: 1) proposed measures to operationalise the evaluation of the legal criteria; 2) suggestions of additional safeguards going beyond these criteria; and 3) remaining fields of tension. RESULTS The initiatives are well in keeping with the legal requirements but are often more stringent. Additional safeguards that are formulated include the need for at least two positive advices from at least two psychiatrists; an a priori evaluation system; and a two-track approach, focusing simultaneously on the assessment of the patient's euthanasia request and on that person's continuing treatment. Although the initiatives are similar in intent, some differences in approach were found, reflecting different ethical stances towards euthanasia and an emphasis on practical clinical assessment versus broad ethical reflection. CONCLUSIONS All initiatives offer useful guidance for the management of euthanasia requests by psychiatric patients. By providing information on, and proper operationalisations of, the legal due care criteria, these initiatives are important instruments to prevent potential abuses. Apart from the additional safeguards suggested, the importance of a decision-making policy that includes many actors (e.g. the patient's relatives and other care providers) and of good aftercare for the bereaved are rightly stressed. Shortcomings of the initiatives relate to the aftercare of patients whose euthanasia request is rejected, and to uncertainty regarding the way in which attending physicians should manage negative or conflicting advices, or patients' suicide threats in case of refusal. Given the scarcity of data on how thoroughly and uniformly requests are handled in practice, it is unclear to what extent the recommendations made in these guidelines are currently being implemented.
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Affiliation(s)
- Monica Verhofstadt
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
| | - Kristof Van Assche
- Research Group Personal Rights and Property Rights, Antwerp University, Stadscampus Venusstraat 23, 2000 Antwerp, Belgium.
| | - Sigrid Sterckx
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Bioethics Institute Ghent, Ghent University, Blandijnberg 2, 9000 Ghent, Belgium.
| | - Kurt Audenaert
- Department of Psychiatry and Medical Psychology, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
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Abstract
'Palliation sedation' is a widely used term to describe the intentional administration of sedatives to reduce a dying person's consciousness to relieve intolerable suffering from refractory symptoms. Research studies generally focus on either 'continuous sedation until death' or 'continuous deep sedation'. It is not always clear whether instances of secondary sedation (i.e. caused by specific symptom management) have been excluded. Continuous deep sedation is controversial because it ends a person's 'biographical life' (the ability to interact meaningfully with other people) and shortens 'biological life'. Ethically, continuous deep sedation is an exceptional last resort measure. Studies suggest that continuous deep sedation has become 'normalized' in some countries and some palliative care services. Of concern is the dissonance between guidelines and practice. At the extreme, there are reports of continuous deep sedation which are best described as non-voluntary (unrequested) euthanasia. Other major concerns relate to its use for solely non-physical (existential) reasons, the under-diagnosis of delirium and its mistreatment, and not appreciating that unresponsiveness is not the same as unconsciousness (unawareness). Ideally, a multiprofessional palliative care team should be involved before proceeding to continuous deep sedation. Good palliative care greatly reduces the need for continuous deep sedation.
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Vanbutsele G, Deliens L, Cocquyt V, Cohen J, Pardon K, Chambaere K. Use and timing of referral to specialized palliative care services for people with cancer: A mortality follow-back study among treating physicians in Belgium. PLoS One 2019; 14:e0210056. [PMID: 30653508 PMCID: PMC6336236 DOI: 10.1371/journal.pone.0210056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 12/17/2018] [Indexed: 12/25/2022] Open
Abstract
Background Referral to specialized palliative care services (SPCS) occurs often late in the illness trajectory but may differ across cancer types. We examined differences between cancer types in the use and timing of referral to specialized palliative care services (SPCS) and in the reasons for non-referral. Methods We conducted a population-based mortality follow-back survey among physicians who certified a representative sample of deaths in Flanders, Belgium. We focused only on sampled death cases of cancer (n = 2392). The questionnaire asked about the use of the existing types of SPCS and the timing of referral to these services. Results Response rate was 58% (1394/2392). Patients who died from breast, respiratory, head and neck, genitourinary or gastrointestinal cancer had higher chances of using SPCS compared to hematologic cancer patients. The most prevalent reason for non-referral was that regular care sufficiently addressed palliative and supportive care needs (51%). This differed significantly between cancer types ranging from 77,8% for breast cancer and 42.1% for hematologic cancer. A second prevalent reason for not using SPCS was that it was not meaningful (enough) (23.9%), particularly for hematologic malignancies (35,1%) and only in 5.3% for breast cancer. Conclusion Differences in referral across different types of cancer were found. Referral is more often delayed or not initiated for patients with hematologic cancer, possibly due to differences in illness trajectory. An influencing reason is that physicians perceive palliative care as not meaningful or not meaningful enough for these patients which may be linked to the uncertainty in the disease trajectory of hematologic malignancies.
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Affiliation(s)
- Gaëlle Vanbutsele
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- * E-mail: (GV); (KC); (KP)
| | - Luc Deliens
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Veronique Cocquyt
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Koen Pardon
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- * E-mail: (GV); (KC); (KP)
| | - Kenneth Chambaere
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- * E-mail: (GV); (KC); (KP)
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Dierickx S, Cohen J, Vander Stichele R, Deliens L, Chambaere K. Drugs Used for Euthanasia: A Repeated Population-Based Mortality Follow-Back Study in Flanders, Belgium, 1998-2013. J Pain Symptom Manage 2018; 56:551-559. [PMID: 30009965 DOI: 10.1016/j.jpainsymman.2018.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/26/2018] [Accepted: 06/28/2018] [Indexed: 11/28/2022]
Abstract
CONTEXT According to guideline recommendations, barbiturates and neuromuscular relaxants are the recommended drugs for euthanasia. OBJECTIVES To describe changes over time in drugs used to perform euthanasia and differences in case characteristics according to the drugs used. METHODS Repeated population-based mortality follow-back study among physicians attending a large representative sample of deaths in 1998, 2007, and 2013 in Flanders, Belgium. RESULTS In 1998, we identified 25 euthanasia cases (1.2% of all deaths), 142 cases in 2007 (2.0% of all deaths), and 349 cases in 2013 (4.6% of all deaths). Use of recommended drugs to perform euthanasia increased from 11.9% of euthanasia cases in 1998 to 55.3% in 2007 and 66.8% in 2013 (P < 0.001). In 2013, cases with recommended drugs compared with nonrecommended drugs more often involved requests expressed both orally and in writing (86.8%/14.1%; P < 0.001), consultation with colleague physicians (93.8%/69.1%; P < 0.001), and administration in the presence of another physician (98.3%/54.3%; P < 0.001), and were more often self-labeled by physicians as euthanasia (95.5%/0.9%; P < 0.001) and reported to the euthanasia review committee (92.3%/3.8%; P < 0.001). Between 2007 and 2013, physicians consistently labeled cases in which nonrecommended drugs were used as palliative sedation (72.8%/78.4%; P = 0.791) or alleviation of pain and symptoms (13.2%/15.0%; P > 0.999). CONCLUSION Physicians in Flanders are increasingly using the recommended drugs for euthanasia. This suggests that guidelines and training regarding the conduct and pharmacological aspects of euthanasia may have had important effects on the practice of euthanasia. However, the declining but persisting use of nonrecommended drugs requires further attention.
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Affiliation(s)
- Sigrid Dierickx
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium; Heymans Institute of Pharmacology, Ghent University, Ghent
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium; Department of Public Health and Primary Care, Ghent University, Ghent
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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Physician-related determinants of medical end-of-life decisions - A mortality follow-back study in Switzerland. PLoS One 2018; 13:e0203960. [PMID: 30235229 PMCID: PMC6147437 DOI: 10.1371/journal.pone.0203960] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/30/2018] [Indexed: 12/12/2022] Open
Abstract
Background Medical end-of-life decisions (MELD) and shared decision-making are increasingly important issues for a majority of persons at the end of life. Little is known, however, about the impact of physician characteristics on these practices. We aimed at investigating whether MELDs depend on physician characteristics when controlling for patient characteristics and place of death. Methods and findings Using a random sample (N = 8,963) of all deaths aged 1 year or older registered in Switzerland between 7 August 2013 and 5 February 2014, questionnaires covering MELD details and physicians' demographics, life stance and medical formation were sent to certifying physicians. The response rate was 59.4% (N = 5,328). Determinants of MELDs were analyzed in binary and multinomial logistic regression models. MELDs discussed with the patient or relatives were a secondary outcome. A total of 3,391 non-sudden nor completely unexpected deaths were used, 83% of which were preceded by forgoing treatment(s) and/or intensified alleviation of pain/symptoms intending or taking into account shortening of life. International medical graduates reported forgoing treatment less often, either alone (RRR = 0.30; 95% CI: 0.21–0.41) or combined with the intensified alleviation of pain and symptoms (RRR = 0.44; 0.34–0.55). The latter was also more prevalent among physicians who graduated in 2000 or later (RRR = 1.60; 1.17–2.19). MELDs were generally less frequent among physicians with a religious affiliation. Shared-decision making was analyzed among 2,542 decedents. MELDs were discussed with patient or relatives less frequently when physicians graduated abroad (OR = 0.65, 95% CI: 0.50–0.87) and more frequently when physicians graduated more recently; physician's sex and religion had no impact. Conclusions Physicians' characteristics, including the country of medical education and time since graduation had a significant effect on the likelihood of an MELD and of shared decision-making. These findings call for additional efforts in physicians' education and training concerning end-of-life practices and improved communication skills.
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Scherrens AL, Roelands M, Van den Block L, Deforche B, Deliens L, Cohen J. What influences intentions to request physician-assisted euthanasia or continuous deep sedation? DEATH STUDIES 2018; 42:491-497. [PMID: 29173079 DOI: 10.1080/07481187.2017.1386734] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The increasing prevalence of euthanasia in Belgium has been linked to changing attitudes. Using National health survey data (N = 9651), we investigated Belgian adults' intention to ask a physician for euthanasia or continuous deep sedation in the hypothetical scenario of a terminal illness and examined its connection to sociodemographic and health characteristics. Respectively, 38.3 and 25.8% could envisage asking for euthanasia and continuous deep sedation. Those with very bad to fair subjective health and with depression more likely had an intention to ask for euthanasia, which suggests need for attention in the evaluation of requests from specific patient groups.
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Affiliation(s)
- Anne-Lore Scherrens
- a Department of Family Medicine and Chronic Care, End-of-Life Care Research Group , Vrije Universiteit Brussel (VUB) and Ghent University , Brussels , Belgium
- b Department of Public Health , Ghent University , Ghent , Belgium
| | - Marc Roelands
- c Department of Public Health Care, Research Group Mental Health and Wellbeing , Vrije Universiteit Brussel (VUB) , Brussels , Belgium
| | - Lieve Van den Block
- a Department of Family Medicine and Chronic Care, End-of-Life Care Research Group , Vrije Universiteit Brussel (VUB) and Ghent University , Brussels , Belgium
| | | | - Luc Deliens
- a Department of Family Medicine and Chronic Care, End-of-Life Care Research Group , Vrije Universiteit Brussel (VUB) and Ghent University , Brussels , Belgium
- d Department of Medical Oncology , Ghent University , Ghent , Belgium
| | - Joachim Cohen
- a Department of Family Medicine and Chronic Care, End-of-Life Care Research Group , Vrije Universiteit Brussel (VUB) and Ghent University , Brussels , Belgium
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Physician-Assisted Suicide: Why Neutrality by Organized Medicine Is Neither Neutral Nor Appropriate. J Gen Intern Med 2018; 33:1394-1399. [PMID: 29722005 PMCID: PMC6082198 DOI: 10.1007/s11606-018-4424-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 12/15/2017] [Accepted: 03/27/2018] [Indexed: 12/25/2022]
Abstract
It has been proposed that medical organizations adopt neutrality with respect to physician-assisted suicide (PAS), given that the practice is legal in some jurisdictions and that membership is divided. We review developments in end-of-life care and the role of medical organizations with respect to the legalization of PAS since the 1990s. We argue that moving from opposition to neutrality is not ethically neutral, but a substantive shift from prohibited to optional. We argue that medical organizations already oppose many practices that are legal in many jurisdictions, and that unanimity among membership has not been required for any other clinical or ethical policy positions. Moreover, on an issue so central to the meaning of medical professionalism, it seems important for organized medicine to take a stand. We subsequently review the arguments in favor of PAS (arguments from autonomy and mercy, and against the distinction between killing and allowing to die (K/ATD)) and the arguments against legalization (the limits of autonomy, effects on the patient-physician relationship, the meaning of healing, the validity of the K/ATD distinction, the social nature of suicide, the availability of alternatives, the propensity for incremental extension, and the meaning of control). We conclude that organized medicine should continue its opposition to PAS.
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Ziegler S, Schmid M, Bopp M, Bosshard G, Puhan MA. Continuous Deep Sedation Until Death-a Swiss Death Certificate Study. J Gen Intern Med 2018; 33:1052-1059. [PMID: 29560568 PMCID: PMC6025678 DOI: 10.1007/s11606-018-4401-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/14/2017] [Accepted: 03/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND In the last decade, the number of patients continuously deeply sedated until death increased up to fourfold. The reasons for this increase remain unclear. OBJECTIVE To identify socio-demographic and clinical characteristics of sedated patients, and concurrent possibly life-shortening medical end-of-life decisions. DESIGN Cross-sectional death certificate study in German-speaking Switzerland in 2001 and 2013. PARTICIPANTS Non-sudden and expected deaths (2001: N = 2281, 2013: N = 2256) based on a random sample of death certificates and followed by an anonymous survey on end-of-life practices among attending physicians. MAIN MEASURES Physicians' reported proportion of patients continuously deeply sedated until death, socio-demographic and clinical characteristics, and possibly life-shortening medical end-of life decisions. KEY RESULTS In 2013, physicians sedated four times more patients continuously until death (6.7% in 2001; 24.5.5% in 2013). Four out of five sedated patients died in hospitals, outside specialized palliative care units, or in nursing homes. Sedation was more likely among patients younger than 65 (odds ratio 2.24, 95% CI 1.6 to 3.2) and those dying in specialized palliative care (OR 2.2, 95% CI 1.3 to 3.8) or in hospitals (1.7, 95% CI 1.3 to 2.3). Forgoing life-prolonging treatment with the explicit intention to hasten or not to postpone death combined with intensified alleviation of symptoms was very strongly associated with continuous deep sedation (OR 6.8, 95% CI 4.7 to 9.8). CONCLUSIONS In Swiss clinical practice, continuously deeply sedated patients predominantly died outside specialized palliative care. The increasing trend over time appears to be related to changes in medical end-of-life practice rather than to patient's clinical characteristics.
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Affiliation(s)
- Sarah Ziegler
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
| | - Margareta Schmid
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Georg Bosshard
- Clinic for Geriatric Medicine, Zurich University Hospital, Zurich, Switzerland
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
- City Hospital Waid, Zurich, Switzerland
| | - Milo Alan Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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Caraceni A, Speranza R, Spoldi E, Ambroset CS, Canestrari S, Marinari M, Marzi AM, Orsi L, Piva L, Rocchi M, Valenti D, Zeppetella G, Zucco F, Raimondi A, Matos LV, Brunelli C. Palliative Sedation in Terminal Cancer Patients Admitted to Hospice or Home Care Programs: Does the Setting Matter? Results From a National Multicenter Observational Study. J Pain Symptom Manage 2018; 56:33-43. [PMID: 29548893 DOI: 10.1016/j.jpainsymman.2018.03.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 11/20/2022]
Abstract
CONTEXT Few studies regarding palliative sedation (PS) have been carried out in home care (HC) setting. A comparison of PS rate and practices between hospice (HS) and HC is also lacking. OBJECTIVES Comparing HC and HS settings for PS rate, patient clinical characteristics before and during PS, decision-making process, and clinical aspects of PS. METHODS About 38 HC/HS services in Italy participated in a multicenter observational longitudinal study. Consecutive adult cancer patients followed till death during a four-month period and undergoing PS were eligible. Symptom control and level of consciousness were registered every eight hours to death. RESULTS About 4276 patients were screened, 2894 followed till death, and 531 (18%) underwent PS. PS rate was 15% in HC and 21% in HS (P < 0.001). Principal refractory symptoms were delirium (54%) and dyspnea (45%), respectively, more common in HC (P < 0.001) and HS (P = 0.03). Informed consent was not obtained in 72% of patients but achieved by 96% of families. Midazolam was the most used drug (94% HS vs. 75% HC; P < 0.001) mainly by continuous infusion (74% HC vs. 89% HS; P < 0.001). PS duration was less than 48 hours in 67% of patients. Hydration during PS was less frequent in HC (27% vs. 49%; P < 0.001). In the eight hours before death, consciousness level was unrousable to mild physical stimulation in 81% and symptom control complete in 89% of cases. CONCLUSION Our results show feasibility of PS in HC and HS and suggest setting differences in rates, indications, and practice of PS, possibly related to patients' selection or care organization.
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Affiliation(s)
- Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Elio Spoldi
- Hospice and Palliative Care Unit, AO Cremona Hospital, Cremona, Italy; Associazione Cremonese contro il dolore (ACCD), Cremona, Italy
| | | | - Stefano Canestrari
- Department of Legal Studies, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | | | | | - Luciano Orsi
- Palliative Care Unit, AO Ospedale Maggiore Crema, Crema, Italy
| | - Laura Piva
- Palliative Care Unit, AO San Paolo Hospital, Milan, Italy
| | - Mirta Rocchi
- Hospice "Casa Madonna dell'Uliveto", Albinea (RE), Italy
| | | | | | - Furio Zucco
- Hospice and Palliative Care Unit, AO G. Salvini, Garbagnate Milanese (MI), Italy
| | - Alessandra Raimondi
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; Department of Cancer Research and Molecular Medicine, European Palliative Care Research Center (PRC), Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
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Sprung CL, Somerville MA, Radbruch L, Collet NS, Duttge G, Piva JP, Antonelli M, Sulmasy DP, Lemmens W, Ely EW. Physician-Assisted Suicide and Euthanasia. J Palliat Care 2018; 33:197-203. [DOI: 10.1177/0825859718777325] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medical professional societies have traditionally opposed physician-assisted suicide and euthanasia (PAS-E), but this opposition may be shifting. We present 5 reasons why physicians shouldn’t be involved in PAS-E. 1. Slippery slopes: There is evidence that safeguards in the Netherlands and Belgium are ineffective and violated, including administering lethal drugs without patient consent, absence of terminal illness, untreated psychiatric diagnoses, and nonreporting; 2. Lack of self-determination: Psychological and social motives characterize requests for PAS-E more than physical symptoms or rational choices; many requests disappear with improved symptom control and psychological support; 3. Inadequate palliative care: Better palliative care makes most patients physically comfortable. Many individuals requesting PAS-E don’t want to die but to escape their suffering. Adequate treatment for depression and pain decreases the desire for death; 4. Medical professionalism: PAS-E transgresses the inviolable rule that physicians heal and palliate suffering but never intentionally inflict death; 5. Differences between means and ends: Proeuthanasia advocates look to the ends (the patient’s death) and say the ends justify the means; opponents disagree and believe that killing patients to relieve suffering is different from allowing natural death and is not acceptable. Conclusions: Physicians have a duty to eliminate pain and suffering, not the person with the pain and suffering. Solutions for suffering lie in improving palliative care and social conditions and addressing the reasons for PAS-E requests. They should not include changing medical practice to allow PAS-E.
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Affiliation(s)
- Charles L. Sprung
- General Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Margaret A. Somerville
- Professor of Bioethics, School of Medicine, The University of Notre Dame Australia, Sydney, Australia; Samuel Gale Professor of Law Emerita, Professor Faculty of Medicine Emerita, Founding Director of the Centre for Medicine, Ethics and Law Emerita, McGill University Montreal, Canada
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | | | - Gunnar Duttge
- Center for Medical Law, Georg-August-University Göttingen, Göttingen, Germany
| | - Jefferson P. Piva
- Federal University of Rio Grande do Sul (Brazil), Medical Director-Pediatric Emergency and Critical Care, Department H Clinicas P. Alegre, Brazil
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore—Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Daniel P. Sulmasy
- Kennedy Institute of Ethics and Pellegrino Center, Departments of Medicine and Philosophy, Georgetown University, Washington D.C., United States
| | - Willem Lemmens
- Department of Philosophy, Centre for Ethics, University of Antwerp, Belgium
| | - E. Wesley Ely
- Department of Medicine, Vanderbilt University Medical Center and Veteran’s Affair TN Valley Geriatric Research Education Clinical Center (GRECC), Nashville, TN, United States
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Cohen J, Dierickx S, Penders YWH, Deliens L, Chambaere K. How accurately is euthanasia reported on death certificates in a country with legal euthanasia: a population-based study. Eur J Epidemiol 2018; 33:689-693. [DOI: 10.1007/s10654-018-0397-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/06/2018] [Indexed: 10/17/2022]
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Hurst SA, Zellweger U, Bosshard G, Bopp M. Medical end-of-life practices in Swiss cultural regions: a death certificate study. BMC Med 2018; 16:54. [PMID: 29673342 PMCID: PMC5909244 DOI: 10.1186/s12916-018-1043-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/23/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND End-of-life decisions remain controversial. Switzerland, with three main languages shared with surrounding countries and legal suicide assistance, allows exploration of the effects of cultural differences on end-of-life practices within the same legal framework. METHODS We conducted a death certificate study on a nationwide continuous random sample of Swiss residents. Using an internationally standardized tool, we sent 4998, 2965, and 1000 anonymous questionnaires to certifying physicians in the German-, French-, and Italian-speaking regions. RESULTS The response rates were 63.5%, 51.9%, and 61.7% in the German-, French-, and Italian-speaking regions, respectively. Non-sudden, expected deaths were preceded by medical end-of-life decisions (MELDs) more frequently in the German- than in the French- or Italian-speaking region (82.3% vs. 75.0% and 74.0%, respectively), mainly due to forgoing life-prolonging treatment (70.0%, 59.8%, 57.4%). Prevalence of assisted suicide was similar in the German- and French-speaking regions (1.6%, 1.2%), with no cases reported in the Italian-speaking region. Patient involvement was smaller in the Italian- than in the French- and German-speaking regions (16.0%, 31.2%, 35.6%). Continuous deep sedation was more frequent in the Italian- than in the French- and German-speaking regions (34.4%, 26.9%, 24.5%), and was combined with MELDs in most cases. CONCLUSION We found differences in MELD prevalence similar to those found between European countries. On an international level, MELDs are comparably frequent in all regions of Switzerland, in line with the greater role given to patient autonomy. Our findings show how cultural contexts and legislation can interact in shaping the prevalence of MELDs.
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Affiliation(s)
- Samia A Hurst
- Institute for Ethics, History, and the Humanities, Geneva University Medical School, 1211, Genève, Switzerland
| | - Ueli Zellweger
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zürich, Switzerland
| | - Georg Bosshard
- Clinic for Geriatric Medicine, Zurich University Hospital, and Center on Aging and Mobility, University of Zurich and City Hospital Waid, Rämistrasse 100, 8091, Zürich, Switzerland
| | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001, Zürich, Switzerland.
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Verkissen MN, Houttekier D, Cohen J, Schots R, Chambaere K, Deliens L. End-of-life decision-making across cancer types: results from a nationwide retrospective survey among treating physicians. Br J Cancer 2018; 118:1369-1376. [PMID: 29593337 PMCID: PMC5959875 DOI: 10.1038/s41416-018-0070-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 02/28/2018] [Accepted: 03/07/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The treatment of advanced cancer often involves potentially life-shortening end-of-life decisions (ELDs). This study aimed to examine the prevalence and characteristics of ELDs in different cancer types. METHODS A nationwide death certificate study was conducted based on a large random sample of all deaths in Flanders, Belgium, between 1 January and 30 June 2013. All cancer deaths were selected (n = 2392). Attending physicians were sent a questionnaire about ELDs and the preceding decision-making process. RESULTS The response rate was 58.3%. Across cancer types, a non-treatment decision occurred in 7.6-14.0%, intensified pain and symptom alleviation in 37.5-41.7%, euthanasia or physician-assisted suicide in 8.7-12.6%, and life shortening without explicit patient request in 1.0-2.4%. ELD prevalence did not differ significantly by cancer type. Reasons for ELDs were most frequently patient's physical suffering and lack of prospect of improvement. 'Anticipated further suffering' and 'unbearable situation for relatives' were reasons more often reported in haematological cancer than in other cancer types. Patient, family, and caregiver involvement in decision-making did not differ across cancer types. CONCLUSIONS Euthanasia or physician-assisted suicide rates were relatively high in all cancer types. Neither the prevalence of ELDs nor characteristics of the decision-making process differed substantially between cancer types. This indicates a uniform approach to end-of-life care, including palliative care, across oncological settings.
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Affiliation(s)
- Mariëtte N Verkissen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Dirk Houttekier
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Rik Schots
- Department of Clinical Haematology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium
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