Euthanasia and palliative sedation in Belgium

The experience of nurses when providing care across acts that may be perceived as death hastening: A qualitative evidence synthesis

BACKGROUND

Nurses can be involved in interventions that they perceive as hastening death. These interventions may intentionally cause death, as in the case of assisted dying or result in death as an unintended consequence, such as when life-sustaining treatment is withdrawn. There is increasing evidence regarding nurses' experiences of providing care in these separate contexts. However, it remains less clear whether parallels exist in experiences across various acts that nurses might consider death hastening.

AIM

To synthesise qualitative research findings on the lived experiences of nurses when involved with acts that may be perceived as death hastening.

DESIGN

A qualitative evidence synthesis utilising thematic synthesis.

DATA SOURCES

An initial search of CINHAL, PsychInfo and Medline was undertaken in December 2022 and updated in August 2024. Papers were quality assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research.

RESULTS

Twenty-three papers were included in the review. An overarching theme linked to the emotional labour required to provide care was developed. Three sub-themes influence emotional labour: (1) experiencing personal and professional conflicts, (2) the provision of 'normal(ised)' care and (3) perceptions of palliative care as a proxy for hastening death.

CONCLUSIONS

This synthesis demonstrates that nurses experience significant emotional labour across acts that may be perceived as death hastening. The level of emotional labour is influenced by nurses' uncertainty of the ethical and moral status of these interventions and navigating these uncertainties alongside colleagues, patients and those important to them during care delivery.

Whose Choice? A Qualitative Inquiry into Professionals' Moral Positions on Euthanasia in Belgium

Death, which was once accepted as an incalculable otherworld journey initiated by the cessation of biological functions, became an object of socio-political regulation in late modernity. Euthanasia, a form of managing death and dying, has grown in popularity with accompanying controversy. What remains under-explored, however, are conceptions of selfhood animating different framings in moral and ethical debates around euthanasia from professional perspectives. Drawing on 20 interviews with physicians and other key professionals in the euthanasia field in Belgium, this study finds that moral division among participants lies in different attributes of selfhood related to euthanasia, which emphasize autonomous, social, or embodied aspects. This paper demonstrates that the diminishing role of religion in appeasing existential anxiety about death, combined with an increasing emphasis on choice as the basis of selfhood, facilitates the contemporary desire to control one's own demise.

Talking About Suffering in the Intensive Care Unit

BACKGROUND

Some have hypothesized that talk about suffering can be used by clinicians to motivate difficult decisions, especially to argue for reducing treatment at the end of life. We examined how talk about suffering is related to decision-making for critically ill patients, by evaluating transcripts of conversations between clinicians and patients' families.

METHODS

We conducted a secondary qualitative content analysis of audio-recorded family meetings from a multicenter trial conducted in the adult intensive care units of five hospitals from 2012-2017 to look at how the term "suffering" and its variants were used. A coding guide was developed by consensus-oriented discussion by four members of the research team. Two coders independently evaluated each transcript. We followed an inductive approach to data analysis in reviewing transcripts; findings were iteratively discussed among study authors until consensus on key themes was reached.

RESULTS

Of 146 available transcripts, 34 (23%) contained the word "suffer" or "suffering" at least once, with 58 distinct uses. Clinicians contributed 62% of first uses. Among uses describing the suffering of persons, 57% (n = 24) were related to a decision, but only 42% (n = 10) of decision-relevant uses accompanied a proposal to limit treatment, and only half of treatment-limiting uses (n = 5) were initiated by clinicians. The target terms had a variety of implicit meanings, including poor prognosis, reduced functioning, pain, discomfort, low quality of life, and emotional distress. Suffering was frequently attributed to persons who were unconscious.

CONCLUSIONS

Our results did not support the claim that the term "suffering" and its variants are used primarily by clinicians to justify limiting treatment, and the terms were not commonly used in our sample when decisions were requested. Still, when these terms were used, they were often used in a decision-relevant fashion.

Medical Assistance in Dying in Neurology

An increasing number of jurisdictions have legalized medical assistance in dying (MAID) with significant variation in the procedures and eligibility criteria used. In the United States, MAID is available for persons with terminal illnesses but is frequently sought by persons with neurologic conditions. Persons with conditions that cause cognitive impairment, such as Alzheimer dementia, are often ineligible for MAID, as their illness is not considered terminal in its early stages, whereas in later stages, they may have impaired decision-making capacity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evolution of European Resuscitation and End-of-Life Practices from 2015 to 2019: A Survey-Based Comparative Evaluation

BACKGROUND

In concordance with the results of large, observational studies, a 2015 European survey suggested variation in resuscitation/end-of-life practices and emergency care organization across 31 countries. The current survey-based study aimed to comparatively assess the evolution of practices from 2015 to 2019, especially in countries with "low" (i.e., average or lower) 2015 questionnaire domain scores.

METHODS

The 2015 questionnaire with additional consensus-based questions was used. The 2019 questionnaire covered practices/decisions related to end-of-life care (domain A); determinants of access to resuscitation/post-resuscitation care (domain B); diagnosis of death/organ donation (domain C); and emergency care organization (domain D). Responses from 25 countries were analyzed. Positive or negative responses were graded by 1 or 0, respectively. Domain scores were calculated by summation of practice-specific response grades.

RESULTS

Domain A and B scores for 2015 and 2019 were similar. Domain C score decreased by 1 point [95% confidence interval (CI): 1-3; p = 0.02]. Domain D score increased by 2.6 points (95% CI: 0.2-5.0; p = 0.035); this improvement was driven by countries with "low" 2015 domain D scores. In countries with "low" 2015 domain A scores, domain A score increased by 5.5 points (95% CI: 0.4-10.6; p = 0.047).

CONCLUSIONS

In 2019, improvements in emergency care organization and an increasing frequency of end-of-life practices were observed primarily in countries with previously "low" scores in the corresponding domains of the 2015 questionnaire.

Physicians’ Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study

As previous research has paid little attention to environmental factors affecting the practice of continuous deep sedation until death (CDS), we aimed to explore these using physicians’ experiences and perceptions. We performed an interpretative thematic analysis of primary data from a qualitative interview study conducted from February to May 2019 in Belgium with 47 physicians. Structural factors were identified: the lack of professional and/or technical support in monitoring sedated patients; the use of guidelines in team contexts; the time constraints for treating individual patients and work pressure; the structural knowledge gap in medical education; the legal context for assisted dying; and the lack of a clear legal context for CDS. Cultural factors were identified: the moral reservations of care teams and/or institutions towards CDS; the presence of a palliative care culture within care teams and institutions; the culture of fear of making clinical errors regarding CDS among a group of physicians; the professional stigma of performing assisted dying among some of the physician population; the different understandings of CDS in medical and policy fields; and the societal taboo around suffering at the end of life and natural death. To conclude, improving CDS practice requires a whole-system approach considering environmental factors.

Odnos medicinskih sester do evtanazije

Uvod: Evtanazija je pojem, o katerem se mora razpravljati z vidika medicinskih, zdravstvenih in družboslovnih strok. Medicinske sestre so sestavni del zdravstvenih timov, zato je potrebno njihovo vključevanje v etične razprave o evtanaziji. Namen pregleda literature je predstaviti vidik evtanazije v povezavi z zdravstveno nego.Metode: Uporabljen je bil pregled literature, izveden v podatkovnih bazah COBIB.SI, CIHAHL in PubMed od 1. 11. 2020 do 1. 12. 2020. Iskanje je potekalo z uporabo ključnih besed: »evtanazija«, »zdravstvena nega«, v angleškem jeziku s kombinacijo ključnih besed: »attitudes«, »euthanasia« in »nursing«. Potek pregleda literature je prikazan z diagramom PRISMA. Kakovost virov, vključenih v končno analizo, je bila ocenjena s pomočjo hierarhije dokazov. Rezultati so bili sintetizirani z uporabo tematske analize.Rezultati: Izmed 138 virov je bilo v končno analizo vključenih enaindvajsetih člankov. Medicinske sestre so navajale naklonjen, kot tudi nenaklonjen odnos ter prisotnost etičnih dilem v povezavi z evtanazijo. Naklonjen odnos medicinskih sester do evtanazije se kaže v primerih neobvladljivih bolečin, neznosnega trpljenja in neozdravljivih bolezni, nenaklonjen pa v povezavi z nekaterimi demografskimi in kulturnimi značilnostmi medicinskih sester, upoštevanjem načel sočutne oskrbe in spoštovanjem vrednosti človekovega življenja.Diskusija in zaključek: Ugotovitve raziskave prispevajo prepoznati odnos medicinskih sester do evtanazije ter nekatere etične dileme v povezavi z evtanazijo. Potrebno bi bilo izvesti podrobne preglede etičnih dilem in moralnih stisk, ki se pojavljajo v povezavi z evtanazijo in zdravstveno nego.

Reporting of Palliative Sedation and Use of Opioids at the End of Life in a Belgian University Hospital: A Pilot Study

Background: Palliative sedation requires no formal registration in Belgium. For euthanasia, however, there are clear guidelines in certain countries, including mandatory registration and evaluation of cases. Official guidelines have been developed for palliative sedation, but research still shows unskilled use of sedation and unclear demarcation between palliative sedation and euthanasia. Registration could be used to avoid unskilled use of sedation and to avoid use or abuse of sedation to hasten the patient's death (described as "slow/passive euthanasia"). Objective: To evaluate the current practice of palliative sedation and use of opioids and sedatives at the end of life by using a registration document. Design: Retrospective observational study. Setting/Subjects: We included all in-hospital deaths at an academic hospital in Belgium of patients (age ≥18 years) who had received parenteral opioids, benzodiazepines, barbiturates, or other anesthetics during the last 24 hours. Measurements: We investigated indications for palliative sedation, patients' and physicians' characteristics, types of medication used, and the decision-making process with the patients and family. The questionnaires were collected between July 9 and November 25, 2016. The study was approved by the Biomedical Ethics Committee of UZ Brussel (B.U.N. 1432016293). Results: In a population of 124 patients, refractory symptoms were reported in 94.4%. All patients received parenteral opioids (intravenously). Benzodiazepines were used in 51.6%. In 75.8%, physicians reported no change in treatment plan during end of life. Hastening death by increasing analgesics and/or sedatives was mentioned in 19.3%. The treatment plan was discussed with patients in 26.6% of cases. In 6 cases, an explicit intention to hasten death was mentioned; in 36 cases, doses of opioids/sedatives may not have been strictly proportional to symptoms. Conclusion: This Belgian study shows that objective reporting of palliative sedation can be used as a tool to ensure good clinical practice where patients receive the most appropriate end-of-life care, avoiding abusive and injudicious or unskilled use of sedation.

Control Measures for Continuous Deep Sedation Until Death: A Framing Analysis of the Views of Physicians

Physicians have been subject to increasing external control to improve their medical practice, and scholars have theorized extensively about their opposition to such control. However, little empirical attention has been paid to the views and reasoning that lie behind this opposition. An in-depth understanding is necessary for enhancing the effectiveness and efficiency of external controls, and continuous deep sedation until death (CDS) is an interesting case in this regard. This study aims to explore how physicians frame control measures for CDS. We conducted 47 semi-structured interviews with Belgian physicians in 2019. A qualitative framing analysis was performed to analyze their views and reasoning. This study reveals that physicians approach CDS practice and control measures with different emphases. Controlling by mechanisms of professional self-regulation and state governance are put forward as appropriate means to improve CDS practice. Policymakers should take into consideration physicians' frames to develop sound control measures.

[Current status of clinical practice guidelines on palliative sedation for adults in French-speaking countries]

INTRODUCTION

Many clinical practice guidelines on palliative sedation have been developed. To date, studies on French-language guidelines are lacking, despite the specific and potentially influential end-of-life positions taken by some French-speaking countries. This study aimed to perform a systematic review of the guidelines related to palliative sedation for adults in French-speaking countries, taking a synchronic and diachronic approach (current and former guidelines).

METHODS

Guidelines published in French since 2000 were searched for multiple databases. In addition, prominent palliative care experts in French-speaking countries were contacted individually. A content analysis of all guidelines was conducted.

RESULTS

A total of 21 guidelines from 18 countries were identified. Among them, at the time of the data collection, 14 guidelines were effectively compiled in four countries or provinces: Belgium, France, Canada (Quebec) and Switzerland. No guidelines were found for African countries. The recommendations analyzed were very heterogeneous in form (simple proposals or formal guidelines) and in substance (i.e. different types of sedation).

DISCUSSION AND CONCLUSION

The quantity and volume of the guidelines found and the heterogeneity of the terminology prevented a detailed analysis of the content of the texts. An analysis must be performed using a synchronic approach only and focusing on a specific element of one type of sedation.