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Piili RP, Hökkä M, Vänskä J, Tolvanen E, Louhiala P, Lehto JT. Facing a request for assisted death - views of Finnish physicians, a mixed method study. BMC Med Ethics 2024; 25:50. [PMID: 38702731 PMCID: PMC11067268 DOI: 10.1186/s12910-024-01051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/28/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Assisted death, including euthanasia and physician-assisted suicide (PAS), is under debate worldwide, and these practices are adopted in many Western countries. Physicians' attitudes toward assisted death vary across the globe, but little is known about physicians' actual reactions when facing a request for assisted death. There is a clear gap in evidence on how physicians act and respond to patients' requests for assisted death in countries where these actions are not legal. METHODS A survey including statements concerning euthanasia and PAS and an open question about their actions when facing a request for assisted death was sent to all Finnish physicians. Quantitative data are presented as numbers and percentages. Statistical significance was tested by using the Pearson chi-square test, when appropriate. The qualitative analysis was performed by using an inductive content analysis approach, where categories emerge from the data. RESULTS Altogether, 6889 physicians or medical students answered the survey, yielding a response rate of 26%. One-third of participants agreed or partly agreed that they could assist a patient in a suicide. The majority (69%) of the participants fully or partly agreed that euthanasia should only be accepted due to difficult physical symptoms, while 12% fully or partly agreed that life turning into a burden should be an acceptable reason for euthanasia. Of the participants, 16% had faced a request for euthanasia or PAS, and 3033 answers from 2565 respondents were achieved to the open questions concerning their actions regarding the request and ethical aspects of assisted death. In the qualitative analysis, six main categories, including 22 subcategories, were formed regarding the phenomenon of how physicians act when facing this request. The six main categories were as follows: providing an alternative to the request, enabling care and support, ignoring the request, giving a reasoned refusal, complying with the request, and seeing the request as a possibility. CONCLUSIONS Finnish physicians' actions regarding the requests for assisted death, and attitudes toward euthanasia and PAS vary substantially. Open discussion, education, and recommendations concerning a request for assisted death and ethics around it are also highly needed in countries where euthanasia and PAS are not legal.
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Affiliation(s)
- Reetta P Piili
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
- Palliative Care Centre, Tampere University Hospital, Palliative Care Unit, Sädetie 6, R-building, Tampere, 33520, Finland.
| | - Minna Hökkä
- Diaconia University of Applied Sciences, Helsinki, Finland
- Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland
| | | | - Elina Tolvanen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Palliative Care Centre, Tampere University Hospital, Palliative Care Unit, Sädetie 6, R-building, Tampere, 33520, Finland
| | - Pekka Louhiala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Juho T Lehto
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Palliative Care Centre, Tampere University Hospital, Palliative Care Unit, Sädetie 6, R-building, Tampere, 33520, Finland
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Rahimian Z, Rahimian L, Lopez‐Castroman J, Ostovarfar J, Fallahi MJ, Nayeri MA, Vardanjani HM. What medical conditions lead to a request for euthanasia? A rapid scoping review. Health Sci Rep 2024; 7:e1978. [PMID: 38515545 PMCID: PMC10955044 DOI: 10.1002/hsr2.1978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 02/07/2024] [Accepted: 02/28/2024] [Indexed: 03/23/2024] Open
Abstract
Background and Aims Euthanasia is a controversial issue related to the right to die. Although euthanasia is mostly requested by terminally sick individuals, even in societies where it is legal, it is unclear what medical conditions lead to euthanasia requests. In this scoping review, we aimed to compile medical conditions for which euthanasia has been requested or performed around the world. Methods The review was preferred reporting items for systematic reviews and meta-analysis for scoping reviews (PRISMA-ScR) checklist. Retrieved search results were screened and unrelated documents were excluded. Data on reasons for conducting or requesting euthanasia along with the study type, setting, and publication year were extracted from documents. Human development index and euthanasia legality were also extracted. Major medical fields were used to categorize reported reasons. Group discussions were conducted if needed for this categorization. An electronic search was undertaken in MEDLINE through PubMed for published documents covering the years January 2000 to September 2022. Results Out of 3323 records, a total of 197 papers were included. The most common medical conditions in euthanasia requests are cancer in a terminal phase (45.4%), Alzheimer's disease and dementia (19.8%), constant unbearable physical or mental suffering (19.8%), treatment-resistant mood disorders (12.2%), and advanced cardiovascular disorders (12.2%). Conclusion Reasons for euthanasia are mostly linked to chronic or terminal physical conditions. Psychiatric disorders also lead to a substantial proportion of euthanasia requests. This review can help to identify the features shared by conditions that lead to performing or requesting euthanasia.
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Affiliation(s)
- Zahra Rahimian
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
- MD‐MPH Department, School of MedicineShiraz University of Medical SciencesShirazIran
| | - Leila Rahimian
- School of DentistryShiraz University of Medical SciencesShirazIran
| | - Jorge Lopez‐Castroman
- Department of Psychiatry, CHU Nîmes & IGFCNRS‐INSERMUniversity of MontpellierMontpellierFrance
- CIBERSAMMadridSpain
| | - Jeyran Ostovarfar
- MD‐MPH Department, School of MedicineShiraz University of Medical SciencesShirazIran
| | - Mohammad J. Fallahi
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical SciencesShirazIran
| | - Mohammad A. Nayeri
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
- MD‐MPH Department, School of MedicineShiraz University of Medical SciencesShirazIran
| | - Hossein M. Vardanjani
- MD‐MPH Department, School of Medicine, Research Center for Traditional Medicine and History of MedicineShiraz University of Medical SciencesShirazIran
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Spitale G, Schneider G, Germani F, Biller-Andorno N. Exploring the role of AI in classifying, analyzing, and generating case reports on assisted suicide cases: feasibility and ethical implications. Front Artif Intell 2023; 6:1328865. [PMID: 38164497 PMCID: PMC10757918 DOI: 10.3389/frai.2023.1328865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/24/2023] [Indexed: 01/03/2024] Open
Abstract
This paper presents a study on the use of AI models for the classification of case reports on assisted suicide procedures. The database of the five Dutch regional bioethics committees was scraped to collect the 72 case reports available in English. We trained several AI models for classification according to the categories defined by the Dutch Termination of Life on Request and Assisted Suicide (Review Procedures) Act. We also conducted a related project to fine-tune an OpenAI GPT-3.5-turbo large language model for generating new fictional but plausible cases. As AI is increasingly being used for judgement, it is possible to imagine an application in decision-making regarding assisted suicide. Here we explore two arising questions: feasibility and ethics, with the aim of contributing to a critical assessment of the potential role of AI in decision-making in highly sensitive areas.
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Affiliation(s)
- Giovanni Spitale
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
| | - Gerold Schneider
- Department of Computational Linguistics, University of Zurich, Zürich, Switzerland
| | - Federico Germani
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
| | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
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Heijltjes MT, van Thiel GJ, Rietjens JA, van der Heide A, Hendriksen G, van Delden JJ. Continuous deep sedation at the end of life: a qualitative interview-study among health care providers on an evolving practice. BMC Palliat Care 2023; 22:160. [PMID: 37880650 PMCID: PMC10601190 DOI: 10.1186/s12904-023-01289-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 10/16/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Continuous deep sedation (CDS) can be used for patients at the end of life who suffer intolerably from severe symptoms that cannot be relieved otherwise. In the Netherlands, the use of CDS is guided by an national guideline since 2005. The percentage of patients for whom CDS is used increased from 8% of all patients who died in 2005 to 18% in 2015. The aim of this study is to explore potential causes of the rise in the use of CDS in the Netherlands according to health care providers who have been participating in this practice. METHODS Semi-structured interviews were conducted and thematically analysed. Participants were Dutch health care providers (HCPs), working at patients' homes, hospices, elderly care facilities and in hospitals and experienced in providing CDS, who were recruited via purposeful sampling. RESULTS 41 Health care providers participated in an interview. For these HCPs the reason to start CDS is often a combination of symptoms resulting in a refractory state. HCPs indicated that symptoms of non-physical origin are increasingly important in the decision to start CDS. Most HCPs felt that suffering at the end of life is less tolerated by patients, their relatives, and sometimes by HCPs; they report more requests to relieve suffering by using CDS. Some HCPs in our study have experienced increasing pressure to perform CDS. Some HCPs stated that they more often used intermittent sedation, sometimes resulting in CDS. CONCLUSIONS This study provides insight into how participating HCPs perceive that their practice of CDS changed over time. The combination of a broader interpretation of refractory suffering by HCPs and a decreased tolerance of suffering at the end of life by patients, their relatives and HCPs, may have led to a lower threshold to start CDS. TRIAL REGISTRATION The Research Ethics Committee of University Medical Center Utrecht assessed that the study was exempt from ethical review according to Dutch law (Protocol number 19-435/C).
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Affiliation(s)
- Madelon T Heijltjes
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, UMC Utrecht, PO Box 85500, Utrecht, 3508 GA, The Netherlands.
| | - Ghislaine Jmw van Thiel
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, UMC Utrecht, PO Box 85500, Utrecht, 3508 GA, The Netherlands
| | - Judith Ac Rietjens
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Geeske Hendriksen
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, UMC Utrecht, PO Box 85500, Utrecht, 3508 GA, The Netherlands
| | - Johannes Jm van Delden
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, UMC Utrecht, PO Box 85500, Utrecht, 3508 GA, The Netherlands
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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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Holmstrand C, Rahm Hallberg I, Saks K, Leino-Kilpi H, Renom Guiteras A, Verbeek H, Zabalegui A, Sutcliffe C, Lethin C. Associated factors of suicidal ideation among older persons with dementia living at home in eight European countries. Aging Ment Health 2021; 25:1730-1739. [PMID: 32223443 DOI: 10.1080/13607863.2020.1745143] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This study aimed to investigate the occurrence of suicidal ideation and associated factors in older persons with dementia living at home in eight European countries, and its association with quality of life. Furthermore, changes in suicidal ideation over time were investigated. METHODS This cohort study (n = 1,223) was part of the European "RightTimePlaceCare" project conducted in 2010-2013. Participating countries were Estonia, Finland, France, Germany, the Netherlands, Spain, Sweden and the United Kingdom. Baseline and follow-up data were analysed using bivariate and multivariate logistic regression. RESULTS The occurrence of suicidal ideation in the participating countries varied between 6% and 24%. Factors significantly (p < 0.0018) associated with suicidal ideation using bivariate analysis were: nationality, depressive symptoms, delusions, hallucinations, agitation, anxiety, apathy, disinhibition, irritability, night-time behaviour disturbances, anxiolytics and anti-dementia medication. In the multivariate regression analysis, country of origin, moderate stage of the dementia, depressive and delusional symptoms, and anti-dementia medication were significantly associated with suicidal ideation (p < 0.05). Over time, suicidal ideation decreased from severe to mild or became absent in 54% of the persons with dementia. CONCLUSION It is essential that professionals identify older persons with dementia and suicidal ideation and depressive and other psychological symptoms in order to give them appropriate treatment and provide relief for their informal caregivers. We emphasize the importance of identifying suicidal ideation, irrespective of depressive symptoms, and specifically of paying attention to persons with moderate dementia. Living with the informal caregiver seems to be associated with staying stable without suicidal ideation.
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Affiliation(s)
- Cecilia Holmstrand
- Faculty of Medicine, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden
| | | | - Kai Saks
- Faculty of Medicine, Department of Internal Medicine, University of Tartu, Tartu, Estonia
| | - Helena Leino-Kilpi
- Department of Nursing Science and Turku University Hospital, University of Turku, Turku, Finland
| | - Anna Renom Guiteras
- Faculty of Health, Department of Nursing Science, University of Witten/Herdecke, Witten, Germany.,Geriatrics Department, University Hospital Parc de Salut Mar, Barcelona, Spain
| | - Hilde Verbeek
- Department of Health Services Research, CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | | | - Caroline Sutcliffe
- Personal Social Services Research Unit, Faculty of Biology, Medicine and Health, Division of Population Health, University of Manchester, Manchester, United Kingdom
| | - Connie Lethin
- Faculty of Medicine, Department of Health Sciences, Lund University, Lund, Sweden.,Faculty of Medicine, Department of Clinical Sciences, Clinical Memory Research Unit, Lund University, Lund/Malmö, Sweden
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Rutherford J, Willmott L, White BP. What the Doctor Would Prescribe: Physician Experiences of Providing Voluntary Assisted Dying in Australia. OMEGA-JOURNAL OF DEATH AND DYING 2021:302228211033109. [PMID: 34282961 DOI: 10.1177/00302228211033109] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Like many countries where voluntary assisted dying (VAD) is legal, eligible doctors in Victoria, Australia, have sole legal authority to provide it. Doctors' attitudes towards legalised VAD have direct bearing on their willingness to participate in VAD and consequently, on whether permissive laws can effectively facilitate access to VAD. The study aimed to explore how some Victorian doctors are perceiving and experiencing the provision of legalised VAD under a recently commenced law. METHODS Semi-structured interviews with 25 Victorian doctors with no in-principle objection to legalised VAD were conducted between July 2019-February 2020. Interviews were recorded, transcribed, and analysed using thematic analysis. Ethical approval from the relevant institution was obtained. RESULTS Doctors perceive or experience VAD to fundamentally challenge traditional medical practice. Barriers to access to VAD derive from applicant, communication, and doctor-related factors. Doctors' willingness to participate in VAD is situation specific.
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Affiliation(s)
- Jodhi Rutherford
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Australia
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Selby D, Meaney C, Bean S, Isenberg-Grzeda E, Nolen A. Factors predicting the risk of loss of decisional capacity for medical assistance in dying: a retrospective database review. CMAJ Open 2020; 8:E825-E831. [PMID: 33293332 PMCID: PMC7743904 DOI: 10.9778/cmajo.20200052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Bill C-14, the legislation that legalized medical assistance in dying (MAiD) in Canada in 2016, outlines eligibility criteria and includes both a mandated 10-day reflection period and a requirement that the patient have capacity to consent at the time MAiD is provided. We examined clinical factors associated with shortened reflection periods or loss of capacity before provision of MAiD. METHODS This retrospective database review involved patients who requested MAiD at a tertiary care hospital in Toronto, Canada, between June 2016 and April 2019. We used logistic regression analyses to examine the association between the combined outcome of unanticipated loss of decisional capacity, shortening of the reflection period or death and the clinical risk factors of interest (age, sex, location of MAiD request [inpatient v. outpatient], score on palliative performance scale [PPS] and diagnosis [cancer v. noncancer]). We generated receiver operating characteristic curves to identify the PPS score (encompassing 5 functional domains: ambulation, activity level, self-care, intake and level of consciousness) that best predicted loss of capacity, shortening of the reflection period or death. RESULTS In total, 155 patients requested assessment for MAiD, and 136 of these were included in the statistical analyses. For 68 patients, the reflection period was not shortened; the other 68 patients lost capacity, died or required shortening of the reflection period. In contrast to the results for age, sex, location of request and diagnosis, the PPS score was associated with loss of capacity or shortening of the reflection period (odds ratio 4.63, 95% confidence interval 2.87-8.23, per 10-point decrease in PPS score). PPS scores less than or equal to 40% balanced sensitivity, specificity and negative predictive value while emphasizing sensitivity to prevent false negative errors. INTERPRETATION The PPS score at the time of MAiD request was strongly associated with loss of capacity or shortening of the reflection period, with lower scores incrementally increasing the risk of these outcomes. For patients with a PPS score of 40% or below, close monitoring is warranted, potentially with plans made to allow rapid provision of MAiD should their clinical condition deteriorate.
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Affiliation(s)
- Debbie Selby
- Sunnybrook Health Sciences Centre (Selby, Bean, Isenberg-Grzeda, Nolen); Department of Family and Community Medicine (Selby, Meaney, Nolen), Dalla Lana School of Public Health (Bean) and Department of Psychiatry (Isenberg-Grzeda), University of Toronto, Toronto, Ont.
| | - Christopher Meaney
- Sunnybrook Health Sciences Centre (Selby, Bean, Isenberg-Grzeda, Nolen); Department of Family and Community Medicine (Selby, Meaney, Nolen), Dalla Lana School of Public Health (Bean) and Department of Psychiatry (Isenberg-Grzeda), University of Toronto, Toronto, Ont
| | - Sally Bean
- Sunnybrook Health Sciences Centre (Selby, Bean, Isenberg-Grzeda, Nolen); Department of Family and Community Medicine (Selby, Meaney, Nolen), Dalla Lana School of Public Health (Bean) and Department of Psychiatry (Isenberg-Grzeda), University of Toronto, Toronto, Ont
| | - Elie Isenberg-Grzeda
- Sunnybrook Health Sciences Centre (Selby, Bean, Isenberg-Grzeda, Nolen); Department of Family and Community Medicine (Selby, Meaney, Nolen), Dalla Lana School of Public Health (Bean) and Department of Psychiatry (Isenberg-Grzeda), University of Toronto, Toronto, Ont
| | - Amy Nolen
- Sunnybrook Health Sciences Centre (Selby, Bean, Isenberg-Grzeda, Nolen); Department of Family and Community Medicine (Selby, Meaney, Nolen), Dalla Lana School of Public Health (Bean) and Department of Psychiatry (Isenberg-Grzeda), University of Toronto, Toronto, Ont
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Gale C, Barak Y. Euthanasia, medically assisted dying or assisted suicide: time for psychiatrists to say no. Australas Psychiatry 2020; 28:160-163. [PMID: 31573331 DOI: 10.1177/1039856219878645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Euthanasia has been considered unethical for most of the history of medicine. Recently it has been legalised in some countries, including parts of Australasia. We describe the recent history of euthanasia, paying attention to the extension of criteria that impact on the poor, elderly and vulnerable members of society in countries that currently have legalised this. In four of the five countries where euthanasia is legalised, there have been extensions of its criteria, either by revision of legislation or changes in practice. CONCLUSIONS We suggest that this dynamic can be halted by international agreements of medical societies to shun involvement in euthanasia, as has been the case with other legal interventions that stigmatise. We may, as we have in the past, need to work collectively to meet this ethical challenge.
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Affiliation(s)
- Chris Gale
- Senior Lecturer, Department of Psychological Medicine, Otago University Medical School, Dunedin, New Zealand
| | - Yoram Barak
- Consultant Psychogeriatrician, Department of Psychological Medicine, Otago University Medical School, Dunedin, New Zealand
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Jakhar J, Ambreen S, Prasad S. Right to Life or Right to Die in Advanced Dementia: Physician-Assisted Dying. Front Psychiatry 2020; 11:622446. [PMID: 33551882 PMCID: PMC7858261 DOI: 10.3389/fpsyt.2020.622446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/17/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jitender Jakhar
- Department of Psychiatry, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, University of Delhi, New Delhi, India
| | - Saaniya Ambreen
- Department of Psychiatry, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, University of Delhi, New Delhi, India
| | - Shiv Prasad
- Faculty of Medical Sciences, Lady Hardinge Medical College, University of Delhi, New Delhi, India
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Capron AM. Looking Back at Withdrawal of Life-Support Law and Policy to See What Lies Ahead for Medical Aid-in-Dying. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2019; 92:781-791. [PMID: 31866795 PMCID: PMC6913806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Current efforts to legalize medical aid-in-dying in this country follow a half century of remarkable legal developments regarding when, how, and on whose terms to intervene to prevent death and extend life in critically and terminally ill patients. The starting point-which I call the first stage along the path-was the creation in the two decades following World War II of powerful means of keeping very ill, and typically unconscious, patients alive. The second stage began in the late 1960s as physicians (and then others in society) began to grapple with the consequences of maintaining such patients on life-support indefinitely. Over five decades, judicial decisions, followed by implementing statutes and regulations, transformed legal rights and medical practices. Are the current developments-which center on legalizing medical aid-in-dying-a third stage along the same path, or do the striking differences between the issues raised about life-sustaining treatment and euthanasia suggest that they are separate? What lessons might those proceeding along the aid-in-dying path take from the development of the other path, and if the two paths are still distinct today, might they merge in the future?
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Affiliation(s)
- Alexander Morgan Capron
- University Professor, Scott H. Bice Chair in Healthcare Law, Policy, and Ethics, Gould School of Law, Professor of Medicine and Law, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Fujioka JK, Mirza RM, Klinger CA, McDonald LP. Medical assistance in dying: implications for health systems from a scoping review of the literature. J Health Serv Res Policy 2019; 24:207-216. [DOI: 10.1177/1355819619834962] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective Medical assistance in dying (MAiD) is the medical provision of substances to end a patient’s life at their voluntary request. While legal in several countries, the implementation of MAiD is met with ethical, legislative and clinical challenges, which are often overshadowed by moral discourse. Our aim was to conduct a scoping review to explore key barriers for the integration of MAiD into existing health systems. Methods We searched electronic databases (CINAHL, Embase, MEDLINE, and PsycINFO) and grey literature sources from 1990 to 2017. Studies discussing barriers and/or challenges to implementing MAiD from a health system’s perspective were included. Full-text papers were screened against inclusion/exclusion criteria for article selection. A thematic content analysis was conducted to summarize data into themes to highlight key implementation barriers. Results The final review included 35 articles (see online Appendix 1). Six categories of implementation challenges emerged: regulatory (n = 26), legal (n = 15), social (n = 9), logistical (n = 9), financial (n = 3) and compatibility with palliative care (n = 3). Within four of the six identified implementation barriers (regulatory, legal, social and logistical) were subthemes, which described barriers related to legalizing MAiD in more detail. Conclusion Despite multiple challenges related to its implementation, MAiD remains a requested end-of-life option, requiring careful examination to ensure adequate integration into existing health services. Comprehensive models of care incorporating multidisciplinary teams and regulatory oversight alongside improved clinician education may be effective to streamline MAiD services.
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Affiliation(s)
- Jamie K. Fujioka
- Researcher, Factor-Inwentash Faculty of Social Work, Institute for Life Course and Aging, University of Toronto, Canada
- Researcher, National Initiative for the Care of the Elderly, Canada
- Researcher, Dalla Lana School of Public Health, University of Toronto, Canada
| | - Raza M. Mirza
- Senior Research Associate, Factor-Inwentash Faculty of Social Work, Institute for Life Course and Aging, University of Toronto, Canada
- Senior Research Associate, National Initiative for the Care of the Elderly, Canada
| | - Christopher A. Klinger
- Senior Research Associate, Factor-Inwentash Faculty of Social Work, Institute for Life Course and Aging, University of Toronto, Canada
- Senior Research Associate, National Initiative for the Care of the Elderly, Canada
| | - Lynn P. McDonald
- Professor, Factor-Inwentash Faculty of Social Work, Institute for Life Course and Aging, University of Toronto, Canada
- Scientific Director, National Initiative for the Care of the Elderly, Canada
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Selby D, Bean S, Isenberg-Grzeda E, Bioethics BHD, Nolen A. Medical Assistance in Dying (MAiD): A Descriptive Study From a Canadian Tertiary Care Hospital. Am J Hosp Palliat Care 2019; 37:58-64. [PMID: 31256607 DOI: 10.1177/1049909119859844] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In June 2016, the Government of Canada passed Bill C-14 decriminalizing medically assisted death. Increasing numbers of Canadians are accessing medical assistance in dying (MAiD) each year, but there is limited information about this population. OBJECTIVE To describe the characteristic outcomes of MAiD requests in a cohort of patients at an academic tertiary care center in Toronto, Ontario, Canada. METHODS A retrospective chart review of patients making a formal request for a MAiD eligibility assessment from July 16 to September 18. Data extracted included demographics, diagnosis, psychosocial characteristics, information relating to the MAiD request, and clinical outcome. RESULTS We received 107 formal requests for MAiD assessment. Ninety-seven patients were found eligible, of whom 80 received MAiD. Cancer was the primary diagnosis for 78% and median age was 74 years. The majority of patients (64%) cited "functional decline or inability to participate in meaningful activities" as the main factor motivating their request for MAiD. Half of patients who received MAiD (46%) described their request as consistent with a long-standing, philosophical view predating their illness. The 10-day reflection period was reduced for 39% of provisions due to impending loss of capacity. Our cohort was very similar demographically to those described both nationally and internationally. CONCLUSION Patients seeking MAiD at our institution were similar to those described in other jurisdictions where assisted dying is legal and represent a group for whom autonomy and independence is critical. We noted a very high rate of risk of loss of capacity, suggesting a need for both earlier assessments and regular monitoring.
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Affiliation(s)
- Debbie Selby
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sally Bean
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elie Isenberg-Grzeda
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | | | - Amy Nolen
- Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Roest B, Trappenburg M, Leget C. The involvement of family in the Dutch practice of euthanasia and physician assisted suicide: a systematic mixed studies review. BMC Med Ethics 2019; 20:23. [PMID: 30953490 PMCID: PMC6451224 DOI: 10.1186/s12910-019-0361-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/27/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Family members do not have an official position in the practice of euthanasia and physician assisted suicide (EAS) in the Netherlands according to statutory regulations and related guidelines. However, recent empirical findings on the influence of family members on EAS decision-making raise practical and ethical questions. Therefore, the aim of this review is to explore how family members are involved in the Dutch practice of EAS according to empirical research, and to map out themes that could serve as a starting point for further empirical and ethical inquiry. METHODS A systematic mixed studies review was performed. The databases Pubmed, Embase, PsycInfo, and Emcare were searched to identify empirical studies describing any aspect of the involvement of family members before, during and after EAS in the Netherlands from 1980 till 2018. Thematic analysis was chosen as method to synthesize the quantitative and qualitative studies. RESULTS Sixty-six studies were identified. Only 14 studies had family members themselves as study participants. Four themes emerged from the thematic analysis. 1) Family-related reasons (not) to request EAS. 2) Roles and responsibilities of family members during EAS decision-making and performance. 3) Families' experiences and grief after EAS. 4) Family and 'the good euthanasia death' according to Dutch physicians. CONCLUSION Family members seem to be active participants in EAS decision-making, which goes hand in hand with ambivalent feelings and experiences. Considerations about family members and the social context appear to be very important for patients and physicians when they request or grant a request for EAS. Although further empirical research is needed to assess the depth and generalizability of the results, this review provides a new perspective on EAS decision-making and challenges the Dutch ethical-legal framework of EAS. Euthanasia decision-making is typically framed in the patient-physician dyad, while a patient-physician-family triad seems more appropriate to describe what happens in clinical practice. This perspective raises questions about the interpretation of autonomy, the origins of suffering underlying requests for EAS, and the responsibilities of physicians during EAS decision-making.
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Affiliation(s)
- Bernadette Roest
- University of Humanistic Studies, Kromme Nieuwegracht 29, 3512HD, Utrecht, The Netherlands.
| | - Margo Trappenburg
- University of Humanistic Studies, Kromme Nieuwegracht 29, 3512HD, Utrecht, The Netherlands
| | - Carlo Leget
- University of Humanistic Studies, Kromme Nieuwegracht 29, 3512HD, Utrecht, The Netherlands
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Fujioka JK, Mirza RM, McDonald PL, Klinger CA. Implementation of Medical Assistance in Dying: A Scoping Review of Health Care Providers' Perspectives. J Pain Symptom Manage 2018; 55:1564-1576.e9. [PMID: 29477968 DOI: 10.1016/j.jpainsymman.2018.02.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/12/2018] [Accepted: 02/13/2018] [Indexed: 11/16/2022]
Abstract
RESEARCH AIMS With the growing interest in Medical Assistance in Dying (MAiD), understanding health care professionals' roles and experiences in handling requests is necessary to evaluate the quality, consistency, and efficacy of current practices. This scoping review sought to map the existing literature on health care providers' perspectives of their involvement in MAiD. METHODS A scoping review was conducted to address the following: 1) What are the roles of diverse health care professionals in the provision of MAiD? and 2) What professional challenges arise when confronted with MAiD requests? A literature search in electronic databases and gray literature sources was performed. Articles were screened, and a thematic content analysis synthesized key findings. RESULTS After evaluating 1715 citations and 148 full-text papers, 33 articles were included. Perspectives of nurses (n = 10), physicians (n = 7), mental health providers (n = 7), pharmacists (n = 4), social workers (n = 3), and medical examiners (n = 1) were explored. Professional roles included consulting/supporting patients and/or other staff members with requests, assessing eligibility, administering/dispensing the lethal drugs, providing aftercare to bereaved relatives, and regulatory oversight. Challenges included lack of clear guidelines/protocols, role ambiguity, evaluating capacity/consent, conscientious objection, and lack of interprofessional collaboration. CONCLUSION Evidence from various jurisdictions highlighted a need for clear guidelines and protocols that define each profession's role, scope of practice, and legal boundaries for MAiD. Comprehensive models of care that incorporate multidisciplinary teams alongside improved clinician education may be effective to support MAiD implementation. Little is known about health care providers' perspectives in handling requests, especially outside physician practice and nursing.
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Affiliation(s)
- Jamie K Fujioka
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada; National Initiative for the Care of the Elderly, Toronto, Ontario, Canada.
| | - Raza M Mirza
- Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada; National Initiative for the Care of the Elderly, Toronto, Ontario, Canada
| | - P Lynn McDonald
- Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada; National Initiative for the Care of the Elderly, Toronto, Ontario, Canada
| | - Christopher A Klinger
- Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada; National Initiative for the Care of the Elderly, Toronto, Ontario, Canada
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Shekhawat RS, Kanchan T, Setia P, Atreya A, Krishan K. Euthanasia: Global Scenario and Its Status in India. SCIENCE AND ENGINEERING ETHICS 2018; 24:349-360. [PMID: 28726026 DOI: 10.1007/s11948-017-9946-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 07/03/2017] [Indexed: 06/07/2023]
Abstract
The legal and moral validity of euthanasia has been questioned in different situations. In India, the status of euthanasia is no different. It was the Aruna Ramachandra Shanbaug case that got significant public attention and led the Supreme Court of India to initiate detailed deliberations on the long ignored issue of euthanasia. Realising the importance of this issue and considering the ongoing and pending litigation before the different courts in this regard, the Ministry of Health and Family Welfare, Government of India issued a public notice on May 2016 that invited opinions from the citizens and the concerned stakeholders on the proposed draft bill entitled The Medical Treatment of Terminally Ill Patients (Protection of Patients and Medical Practitioners) Bill. Globally, only a few countries have legislation with discreet and unambiguous guidelines on euthanasia. The ongoing developments have raised a hope of India getting a discreet law on euthanasia in the future.
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Affiliation(s)
- Raghvendra Singh Shekhawat
- Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Jodhpur, India.
| | - Tanuj Kanchan
- Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Jodhpur, India
| | - Puneet Setia
- Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Jodhpur, India
| | - Alok Atreya
- Department of Forensic Medicine, Nepal Medical College Teaching Hospital, Kathmandu, Nepal, India
| | - Kewal Krishan
- Department of Anthropology, Panjab University, Chandigarh, India
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17
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Osterthun R, van Asbeck FWA, Nijendijk JHB, Post MWM. In-hospital end-of-life decisions after new traumatic spinal cord injury in the Netherlands. Spinal Cord 2016; 54:1025-1030. [DOI: 10.1038/sc.2016.37] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/11/2016] [Accepted: 02/18/2016] [Indexed: 11/09/2022]
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Berghmans RLP, Widdershoven GAM. Euthanasia in the Netherlands: Consultation and Review. ACTA ACUST UNITED AC 2015. [DOI: 10.5235/klj.23.2.109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ron LP Berghmans
- Maastricht University, Department of Health, Ethics and Society, CAPHRI School for Public Health and Primary Care, The Netherlands
| | - Guy AM Widdershoven
- VU University Medical Center, Amsterdam, EMGO Institute for Health and Care Research, Department of Medical Humanities, The Netherlands
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Köneke V. Trust increases euthanasia acceptance: a multilevel analysis using the European Values Study. BMC Med Ethics 2014; 15:86. [PMID: 25528457 PMCID: PMC4289573 DOI: 10.1186/1472-6939-15-86] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 12/16/2014] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND This study tests how various kinds of trust impact attitudes toward euthanasia among the general public. The indication that trust might have an impact on euthanasia attitudes is based on the slippery slope argument, which asserts that allowing euthanasia might lead to abuses and involuntary deaths. Adopting this argument usually leads to less positive attitudes towards euthanasia. Tying in with this, it is assumed here that greater trust diminishes such slippery slope fears, and thereby increases euthanasia acceptance. METHODS The effects of various trust indicators on euthanasia acceptance were tested using multilevel analysis, and data from the European Values Study 2008 (N = 49,114, 44 countries). More precisely, the influence of people's general levels of trust in other people, and their confidence in the health care system, were measured--both at the individual and at the country level. Confidence in the state and the press were accounted for as well, since both institutions might monitor and safeguard euthanasia practices. RESULTS It was shown that the level of trust in a country was strongly positively linked to euthanasia attitudes, both for general trust and for confidence in health care. In addition, within countries, people who perceived their fellow citizens as trustworthy, and who had confidence in the press, were more supportive of euthanasia than their less trusting counterparts. The pattern was, however, not true for confidence in the state and for confidence in the health care system at the individual level. Notably, all confirmative effects held, even when other variables such as religiosity, education, and values regarding autonomy were controlled for. CONCLUSIONS Trust seems to be a noteworthy construct to explain differences in attitudes towards euthanasia, especially when drawing cross-country comparisons. Therefore, it should be added to the existing literature on correlates of euthanasia attitudes.
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Affiliation(s)
- Vanessa Köneke
- Cologne Graduate School and SOCLIFE Research Training Group, University of Cologne, Albertus-Magnus-Platz, 50931 Cologne, Germany.
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20
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Advance health care directives and "public guardian": the Italian supreme court requests the status of current and not future inability. BIOMED RESEARCH INTERNATIONAL 2014; 2014:576391. [PMID: 24729977 PMCID: PMC3963218 DOI: 10.1155/2014/576391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 01/29/2014] [Accepted: 02/01/2014] [Indexed: 11/17/2022]
Abstract
Advance health care decisions animate an intense debate in several European countries, which started more than 20 years ago in the USA and led to the adoption of different rules, based on the diverse legal, sociocultural and philosophical traditions of each society. In Italy, the controversial issue of advance directives and end of life's rights, in the absence of a clear and comprehensive legislation, has been over time a subject of interest of the Supreme Court. Since 2004 a law introduced the “Public Guardian,” aiming to provide an instrument of assistance to the person lacking in autonomy because of an illness or incapacity. Recently, this critical issue has once again been brought to the interest of the Supreme Court, which passed a judgment trying to clarify the legislative application of the appointment of the Guardian in the field of advance directives.
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21
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Cohen-Almagor R. First do no harm: pressing concerns regarding euthanasia in Belgium. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2013; 36:515-21. [PMID: 23859807 DOI: 10.1016/j.ijlp.2013.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
This article is concerned with the practice of euthanasia in Belgium. Background information is provided; then major developments that have taken place since the enactment of the Belgian Act on Euthanasia are analysed. Concerns are raised about (1) the changing role of physicians and imposition on nurses to perform euthanasia; (2) the physicians' confusion and lack of understanding of the Act on Euthanasia; (3) inadequate consultation with an independent expert; (4) lack of notification of euthanasia cases, and (5) organ transplantations of euthanized patients. Some suggestions designed to improve the situation and prevent abuse are offered.
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Thulesius HO, Scott H, Helgesson G, Lynöe N. De-tabooing dying control - a grounded theory study. BMC Palliat Care 2013; 12:13. [PMID: 23496849 PMCID: PMC3602181 DOI: 10.1186/1472-684x-12-13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 02/26/2013] [Indexed: 11/23/2022] Open
Abstract
Background Dying is inescapable yet remains a neglected issue in modern health care. The research question in this study was “what is going on in the field of dying today?” What emerged was to eventually present a grounded theory of control of dying focusing specifically on how people react in relation to issues about euthanasia and physician-assisted suicide (PAS). Methods Classic grounded theory was used to analyze interviews with 55 laypersons and health care professionals in North America and Europe, surveys on attitudes to PAS among physicians and the Swedish general public, and scientific literature, North American discussion forum websites, and news sites. Results Open awareness of the nature and timing of a patient’s death became common in health care during the 1960s in the Western world. Open dying awareness contexts can be seen as the start of a weakening of a taboo towards controlled dying called de-tabooing. The growth of the hospice movement and palliative care, but also the legalization of euthanasia and PAS in the Benelux countries, and PAS in Montana, Oregon and Washington further represents de-tabooing dying control. An attitude positioning between the taboo of dying control and a growing taboo against questioning patient autonomy and self-determination called de-paternalizing is another aspect of de-tabooing. When confronted with a taboo, people first react emotionally based on “gut feelings” - emotional positioning. This is followed by reasoning and label wrestling using euphemisms and dysphemisms - reflective positioning. Rarely is de-tabooing unconditional but enabled by stipulated positioning as in soft laws (palliative care guidelines) and hard laws (euthanasia/PAS legislation). From a global perspective three shapes of dying control emerge. First, suboptimal palliative care in closed awareness contexts seen in Asian, Islamic and Latin cultures, called closed dying. Second, palliative care and sedation therapy, but not euthanasia or PAS, is seen in Europe and North America, called open dying with reversible medical control. Third, palliative care, sedation therapy, and PAS or euthanasia occurs together in the Benelux countries, Oregon, Washington and Montana, called open dying with irreversible medical control. Conclusions De-tabooing dying control is an assumed secular process starting with open awareness contexts of dying half a century ago, and continuing with the growth of the palliative care movement and later euthanasia and PAS legislation.
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Affiliation(s)
- Hans O Thulesius
- Department of Clinical Sciences Malmö, Division of Family Medicine, Lund University, Lund, Sweden.
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23
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Goel A, Chhabra G, Weijma R, Solari M, Thornton S, Achondo B, Pruthi S, Gupta V, Kalantri SP, Ramavat AS, Kalra OP. End-of-Life Care Attitudes, Values, and Practices Among Health Care Workers. Am J Hosp Palliat Care 2013; 31:139-47. [DOI: 10.1177/1049909113479440] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: This study aims to ascertain attitudes of health care workers on end-of-life care (EOLC) issues and to highlight the disparity that exists in countries with different backgrounds. Methods: It is a cross-sectional questionnaire survey across heterogeneous health care providers in India, Chile, the United Kingdom, and the Netherlands using an indigenously prepared questionnaire considering regional variations, covering different areas of EOLC. Results: Of the 109 participants, 68 (62.4%) felt that cardiopulmonary resuscitation should be done selectively, 25 (22.9%) had come in contact with at least 1 patient who had asked them to hasten death, and 36 (33%) felt that training was insufficient to prepare them for skills in issues of EOLC. Conclusion: To avoid cumbersome through well-meant interventions, it is important that the caregiving team is aware of the patient’s own wishes with respect to EOLC issues.
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Affiliation(s)
- Ashish Goel
- University College of Medical Sciences, Delhi, India
| | | | - Robyn Weijma
- VU University Medical Centre, Amsterdam, the Netherlands
| | - Marla Solari
- Centro de Salud Familiar, Fundacion Cristo Vive, Recoleta, Santiago, Chile
| | - Sarah Thornton
- Department of Anaesthesia, Royal Bolton Hospital, Bolton , United Kingdom
| | - Bernardita Achondo
- Centro de Salud Familiar, Fundacion Cristo Vive, Recoleta, Santiago, Chile
| | - Sonal Pruthi
- University College of Medical Sciences, Delhi, India
| | - Vineet Gupta
- University of Pittsburgh Medical Center (UPMC) Mercy, Pittsburgh, PA, USA
| | - S. P. Kalantri
- Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
| | - Anurag S. Ramavat
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - O. P. Kalra
- University College of Medical Sciences, Delhi, India
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Glebocka A, Gawor A, Ostrowski F. Attitudes toward euthanasia among Polish physicians, nurses and people who have no professional experience with the terminally ill. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 788:407-12. [PMID: 23836005 DOI: 10.1007/978-94-007-6627-3_55] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Euthanasia is an issue that generates an extensive social debate. Euthanasia is generally classified as either active or passive. The former is usually defined as taking specific steps to cause the patient's death, while the latter is described as withdrawal of medical treatment with the deliberate intention of bringing the patient's life to an end. The dispute on euthanasia involves a multitude of aspects including religious, legal, cultural, ethical, medical, and spiritual issues. The purpose of the present study was to examine the views of medical professionals toward the highly controversial issue of euthanasia. Accordingly, the research has been conducted among a group of Polish nurses and physicians working in Intensive Care and Oncology Units. Their views have been compared to those of the control group, which included the members of the general public, who do not work in medical profession. It was expected that the education and training and the day-to-day exposure to vegetative patients might influence the views of medical personnel concerning euthanasia. The research demonstrated that the members of all groups supported liberal views. Conservative views were not popular among the respondents. The physicians turned out to be the least conservative group. The survey has also demonstrated that there is a broad consensus that informational and psychological support should be provided to terminally ill patients and their relatives. The attitude toward the passive form of euthanasia seems to have broad support. In particular doctors tend to approve this form of bringing a terminally ill patient's life to an end. The active euthanasia is regarded with much less favor and physicians, in particular, appear to disapprove of it.
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Affiliation(s)
- A Glebocka
- Faculty of Psychology and Humanistic Science, The Andrzej Frycz Modrzewski Krakow University, 1 Gustawa Herlinga-Grudzinskiego St., 30-705, Krakow, Poland,
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Khan F, Tadros G. Physician-assisted Suicide and Euthanasia in Indian Context: Sooner or Later the Need to Ponder! Indian J Psychol Med 2013; 35:101-5. [PMID: 23833354 PMCID: PMC3701348 DOI: 10.4103/0253-7176.112220] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Physician-assisted suicide (PAS) is a controversial subject which has recently captured the interest of media, public, politicians, and medical profession. Although active euthanasia and PAS are illegal in most parts of the world, with the exception of Switzerland and the Netherlands, there is pressure from some politicians and patient support groups to legalize this practice in and around Europe that could possibly affect many parts of the world. The legal status of PAS and euthanasia in India lies in the Indian Penal Code, which deals with the issues of euthanasia, both active and passive, and also PAS. According to Penal Code 1860, active euthanasia is an offence under Section 302 (punishment for murder) or at least under Section 304 (punishment for culpable homicide not amounting to murder). The difference between euthanasia and physician assisted death lies in who administers the lethal dose; in euthanasia, this is done by a doctor or by a third person, whereas in physician-assisted death, this is done by the patient himself. Various religions and their aspects on suicide, PAS, and euthanasia are discussed. People argue that hospitals do not pay attention to patients' wishes, especially when they are suffering from terminally ill, crippling, and non-responding medical conditions. This is bound to change with the new laws, which might be implemented if PAS is legalized. This issue is becoming relevant to psychiatrists as they need to deal with mental capacity issues all the time.
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Affiliation(s)
- Farooq Khan
- Consultant Psychiatrist, Mental Helath Services for Older People, Staffordshire University, BL 167 Blackhealth Lane, Stafford ST18 0AD, UK
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Abstract
BACKGROUND Euthanasia requests have increased as the number of debilitated patients rises in both developed and developing countries such as India due to medical, psychosocial-emotional, socioenvironmental, and existential issues amid fears of potential misuse. WORLD'S POSITION: Albania, Colombia, the Netherlands, and Switzerland permit euthanasia conditionally. Australia's legalization of euthanasia has been withdrawn. The United States permits withdrawal of life support. Mexico and Norway permit active euthanasia. INDIA'S POSITION: Following the Aruna Shanbaug case the Supreme Court granted legal sanction to passive, but not active, euthanasia that is valid till the Parliament legislates on euthanasia. HANDLING EUTHANASIA REQUESTS: Acknowledging the complexity of the problem; individualizing the palliative approach; and accepting the 'There is no alternative' or 'There is no answer' (TINA) factor.
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Affiliation(s)
- Skand Shekhar
- 1University College of Medical Sciences, Delhi, India
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Beydon L, Pelluchon C, Beloucif S, Baghdadi H, Baumann A, Bazin JE, Bizouarn P, Crozier S, Devalois B, Eon B, Fieux F, Frot C, Gisquet E, Guibet Lafaye C, Kentish-Barnes N, Muzard O, Nicolas-Robin A, Lopez MO, Roussin F, Puybasset L. [Euthanasia, assisted suicide and palliative care: a review by the Ethics Committee of the French Society of Anaesthesia and Intensive Care]. ACTA ACUST UNITED AC 2012; 31:694-703. [PMID: 22922010 DOI: 10.1016/j.annfar.2012.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 07/19/2012] [Indexed: 10/28/2022]
Abstract
CONTEXT Management of the end of life is a major social issue which was addressed in France by law, on April 22nd 2005. Nevertheless, a debate has emerged within French society about the legalization of euthanasia and/or assisted suicide (E/AS). This issue raises questions for doctors and most especially for anesthetists and intensive care physicians. OBJECTIVE To highlight, dispassionately and without dogmatism, key points taken from the published literature and the experience of countries which have legislated for E/AS. RESULTS The current French law addresses most of the end of life issues an intensive care physician might encounter. It is credited for imposing palliative care when therapies have become senseless and are withdrawn. However, this requirement for palliative care is generally applied too late in the course of a fatal illness. There is a great need for more education and stronger incentives for early action in this area. On the rare occasions when E/AS is requested, either by the patient or their loved-ones, it often results from a failure to consider that treatments have become senseless and conflict with patient's best interest. The implementation of E/AS cannot be reduced to a simple affirmation of the Principle of autonomy. Such procedures present genuine difficulties and the risk of drift. CONCLUSION We deliver a message of prudence and caution. Should we address painful end of life and moral suffering issues, by suppressing the subject, i.e. ending the patient's life, when comprehensive palliative care has not first been fully granted to all patients in need of it ?
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Affiliation(s)
- L Beydon
- Pôle d'anesthésie-réanimation, centre hospitalier universitaire d'Angers, 4, rue Larrey, 49033 Angers cedex 01, France.
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Ruijs CD, Kerkhof AJ, van der Wal G, Onwuteaka-Philipsen BD. The broad spectrum of unbearable suffering in end-of-life cancer studied in dutch primary care. BMC Palliat Care 2012; 11:12. [PMID: 22853448 PMCID: PMC3453495 DOI: 10.1186/1472-684x-11-12] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 06/19/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unbearable suffering most frequently is reported in end-of-life cancer patients in primary care. However, research seldom addresses unbearable suffering. The aim of this study was to comprehensively investigate the various aspects of unbearable suffering in end-of-life cancer patients cared for in primary care. METHODS Forty four general practitioners recruited end-of-life cancer patients with an estimated life expectancy of half a year or shorter. The inclusion period was three years, follow-up lasted one additional year. Practices were monitored bimonthly to identify new cases. Unbearable aspects in five domains and overall unbearable suffering were quantitatively assessed (5-point scale) through patient interviews every two months with a comprehensive instrument. Scores of 4 (serious) or 5 (hardly can be worse) were defined unbearable. The last interviews before death were analyzed. Sources providing strength to bear suffering were identified through additional open-ended questions. RESULTS Seventy six out of 148 patients (51%) requested to participate consented; the attrition rate was 8%, while 8% were alive at the end of follow-up. Sixty four patients were followed up until death; in 60 patients interviews were complete. Overall unbearable suffering occurred in 28%. A mean of 18 unbearable aspects was present in patients with serious (score 4) overall unbearable suffering. Overall, half of the unbearable aspects involved the domain of traditional medical symptoms. The most frequent unbearable aspects were weakness, general discomfort, tiredness, pain, loss of appetite and not sleeping well (25%-57%). The other half of the unbearable aspects involved the domains of function, personhood, environment, and nature and prognosis of disease. The most frequent unbearable aspects were impaired activities, feeling dependent, help needed with housekeeping, not being able to do important things, trouble accepting the situation, being bedridden and loss of control (27%-55%). The combination of love and support was the most frequent source (67%) providing strength to bear suffering. CONCLUSIONS Overall unbearable suffering occurred in one in every four end-of-life cancer patients. Half of the unbearable aspects involved medical symptoms, the other half concerned psychological, social and existential dimensions. Physicians need to comprehensively assess suffering and provide psychosocial interventions alongside physical symptom management.
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Affiliation(s)
- Cees Dm Ruijs
- Department of Public and Occupational Health, VU University Medical Centre, Amsterdam, The Netherlands.
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Ruijs CDM, Goedhart J, Kerkhof AJFM, van der Wal G, Onwuteaka-Philipsen BD. Recruiting end-of-life cancer patients in the Netherlands for a study on suffering and euthanasia requests. Fam Pract 2011; 28:689-95. [PMID: 21677047 DOI: 10.1093/fampra/cmr035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In the Netherlands, GPs performed euthanasia or physician-assisted suicide (EAS) in ∼1 of 10 end-of-life cancer patients in their care. Of all explicit requests for EAS directed at GPs, ∼44% resulted in EAS. However, the suffering of patients who do and do not request EAS has never been studied. An important barrier for such research is the low prevalence of end-of-life cancer patients per practice (on average two/year). We studied whether it is possible to recruit end-of-life cancer patients, following-up for requests for EAS (if any), in an interview study in general practice, whether selection occurred and which were the threats and opportunities to recruitment. Our target was to recruit at least 50 patients. METHODS Characteristics of all eligible patients were monitored. RESULTS One in every three eligible patients were recruited by 44 GPs in a 3-year inclusion period, resulting in 64 patients in the interview study with follow-up until death. The prevalence of explicit requests for EAS was higher (27%; P = 0.026) in the interview sample, and the presence of a depressed mood according to the GP was lower (5%; P = 0.013) than in the sample with eligible but not participating patients. CONCLUSIONS Recruitment of slightly more than the minimal target number of end-of-life cancer patients in this study in general practice was realized. Monitoring of all eligible patients permitted to evaluate the selection which occurred. Recruitment through GPs who were direct professional colleagues of one of the researchers was a positive recruitment factor.
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Affiliation(s)
- C D M Ruijs
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Palliative Care Centre of Expertise, VU University Medical Centre, Amsterdam.
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Bleek J. Ist die Beihilfe zum Suizid auf der Grundlage des Wunsches, anderen nicht zur Last zu fallen, ethisch gerechtfertigt? Ethik Med 2011. [DOI: 10.1007/s00481-011-0148-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Buiting HM, Willems DL, Pasman HRW, Rurup ML, Onwuteaka-Philipsen BD. Palliative treatment alternatives and euthanasia consultations: a qualitative interview study. J Pain Symptom Manage 2011; 42:32-43. [PMID: 21477981 DOI: 10.1016/j.jpainsymman.2010.10.260] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 09/29/2010] [Accepted: 10/06/2010] [Indexed: 01/03/2023]
Abstract
CONTEXT There is much debate about euthanasia within the context of palliative care. The six criteria of careful practice for lawful euthanasia in The Netherlands aim to safeguard the euthanasia practice against abuse and a disregard of palliative treatment alternatives. Those criteria need to be evaluated by the treating physician as well as an independent euthanasia consultant. OBJECTIVES To investigate 1) whether and how palliative treatment alternatives come up during or preceding euthanasia consultations and 2) how the availability of possible palliative treatment alternatives are assessed by the independent consultant. METHODS We interviewed 14 euthanasia consultants and 12 physicians who had requested a euthanasia consultation. We transcribed and analyzed the interviews and held consensus meetings about the interpretation. RESULTS Treating physicians generally discuss the whole range of treatment options with the patient before the euthanasia consultation. Consultants actively start thinking about and proposing palliative treatment alternatives after consultations, when they have concluded that the criteria for careful practice have not been met. During the consultation, they take into account various aspects while assessing the criterion concerning the availability of reasonable alternatives, and they clearly distinguish between euthanasia and continuous deep sedation. Most consultants said that it was necessary to verify which forms of palliative care had previously been discussed. Advice concerning palliative care seemed to be related to the timing of the consultation ("early" or "late"). Euthanasia consultants were sometimes unsure whether or not to advise about palliative care, considering it not their task or inappropriate in view of the previous discussions. CONCLUSION Two different roles of a euthanasia consultant were identified: a limited one, restricted to the evaluation of the criteria for careful practice, and a broad one, extended to actively providing advice about palliative care. Further medical and ethical debate is needed to determine consultants' most appropriate role.
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Affiliation(s)
- Hilde M Buiting
- VU University Medical Center, EMGO Institute for Health and Care Research, Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam, The Netherlands.
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Karlsson M, Milberg A, Strang P. Suffering and euthanasia: a qualitative study of dying cancer patients' perspectives. Support Care Cancer 2011; 20:1065-71. [PMID: 21573739 DOI: 10.1007/s00520-011-1186-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 05/02/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE Although intolerable suffering is a core concept used to justify euthanasia, little is known about dying cancer patients' own interpretations and conclusions of suffering in relation to euthanasia. METHODS Sixty-six patients with cancer in a palliative phase were selected through maximum-variation sampling, and in-depth interviews were conducted on suffering and euthanasia. The interviews were analyzed using qualitative content analysis with no predetermined categories. RESULTS The analysis demonstrated patients' different perspectives on suffering in connection to their attitude to euthanasia. Those advocating euthanasia, though not for themselves at the time of the study, did so due to (1) perceptions of suffering as meaningless, (2) anticipatory fears of losses and multi-dimensional suffering, or (3) doubts over the possibility of receiving help to alleviate suffering. Those opposing euthanasia did so due to (1) perceptions of life, despite suffering, as being meaningful, (2) trust in bodily or psychological adaptation to reduce suffering, a phenomenon personally experienced by informants, and (3) by placing trust in the provision of help and support by healthcare services to reduce future suffering. CONCLUSIONS Dying cancer patients draw varying conclusions from suffering: suffering can, but does not necessarily, lead to advocations of euthanasia. Patients experiencing meaning and trust, and who find strategies to handle suffering, oppose euthanasia. In contrast, patients with anticipatory fears of multi-dimensional meaningless suffering and with lack of belief in the continuing availability of help, advocate euthanasia. This indicates a need for healthcare staff to address issues of trust, meaning, and anticipatory fears.
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Affiliation(s)
- Marit Karlsson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.
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CQ Sources/Bibliography. Camb Q Healthc Ethics 2010. [DOI: 10.1017/s0963180110000186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
These CQ Sources were compiled by Bette Anton.
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