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van den Ende C, Asscher ECA. No (true) right to die: barriers in access to physician-assisted death in case of psychiatric disease, advanced dementia or multiple geriatric syndromes in the Netherlands. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024; 27:181-188. [PMID: 38376767 PMCID: PMC11076306 DOI: 10.1007/s11019-023-10190-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 02/21/2024]
Abstract
Even in the Netherlands, where the practice of physician-assisted death (PAD) has been legalized for over 20 years, there is no such thing as a 'right to die'. Especially patients with extraordinary requests, such as a wish for PAD based on psychiatric suffering, advanced dementia, or (a limited number of) multiple geriatric syndromes, encounter barriers in access to PAD. In this paper, we discuss whether these barriers can be justified in the context of the Dutch situation where PAD is legally permitted for those who suffer unbearably and hopelessly as a result of medical conditions. Furthermore, we explore whether there are options to address some of the barriers or their consequences, both within the Dutch legal framework or by adjusting the legal framework, and whether these options are feasible. We conclude that although there are insufficient arguments to overrule the doctor's freedom of conscience in the Netherlands, there are ways to address some of the barriers, mainly by offering support to doctors that would be willing to support a request. Moreover, we believe it is morally required to reduce or mitigate where possible the negative consequences of the barriers for patients, such as the long waiting time for those who suffer from psychiatric disorders, because it is unlikely the adjustments suggested to the system will ensure reasonable access for these patient groups.
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Affiliation(s)
- Caroline van den Ende
- Department of General Practice/Family Medicine, Amsterdam UMC, Amsterdam, The Netherlands.
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2
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Verdaguer M, Beroiz-Groh P, Busquet-Duran X, Moreno-Gabriel E, Arreciado Marañón A, Feijoo-Cid M, Domènech M, Íñiguez-Rueda L, Vallès-Peris N, Cantarell-Barella G, Toran-Monserrat P. [The euthanasia law and professional experiences: tensions in clinical practice]. GACETA SANITARIA 2024:S0213-9111(24)00020-7. [PMID: 38472012 DOI: 10.1016/j.gaceta.2024.102373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 03/14/2024]
Abstract
OBJECTIVE To analyze the process of assisted death provision in Catalonia and identify the main tensions, difficulties, and/or sources of discomfort related to professional practice. METHOD A qualitative study was conducted based on interviews (n=29) and focus groups (n=19) with professionals who participated in the euthanasia process. The selection of participants combined the snowball and maximization of variability procedures, taking into account the variables of professional profile, setting, gender, age and territoriality. Intentional and theoretical sampling process. RESULTS The assisted death process is divided into four main moments: 1) reception of the request, 2) medical-bureaucratic procedure, 3) the actual procedure, and 4) closure. At each of these moments, difficulties arise that can be a source of discomfort and have to do with the limits and tensions between the legal and moral, the conception of one's own professional role, the lack of recognition of some professional roles, stress and overload, the lack of formal and informal support, and the relationship with the patient and his/her family. The bureaucratic-administrative stress derived from a protective law, with both prior and subsequent verifying control, stands out, given that it stresses the professionals immersed in a healthcare system already under high pressure after budget cuts and the COVID-19 epidemic. CONCLUSIONS Throughout the assisted death process, the sources of distress are diverse and of a psychological, psychosocial, and structural nature. These results may lead to interventions for psychological and peer support, information, training, institutional involvement, and burden reduction.
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Affiliation(s)
- Maria Verdaguer
- Unitat de Suport a la Recerca Metropolitana Nord, Institut Universitari d'Investigació en Atenció Primària Jordi Gol i Gurina, Mataró (Barcelona), España; Departament de Psicologia Social, Facultat de Psicologia, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España.
| | - Patricia Beroiz-Groh
- Hospital Germans Trias i Pujol, Badalona (Barcelona), España; Departament de Medicina, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España
| | - Xavier Busquet-Duran
- Unitat de Suport a la Recerca Metropolitana Nord, Institut Universitari d'Investigació en Atenció Primària Jordi Gol i Gurina, Mataró (Barcelona), España; Grup de Recerca Multidisciplinari en Salut i Societat, Barcelona, España; Programa d'Atenció Domiciliària Equip de Suport, Servei d'Atenció Primària Vallès Oriental, Institut Català de la Salut, Granollers (Barcelona), España
| | - Eduard Moreno-Gabriel
- Unitat de Suport a la Recerca Metropolitana Nord, Institut Universitari d'Investigació en Atenció Primària Jordi Gol i Gurina, Mataró (Barcelona), España; Grup de Recerca Multidisciplinari en Salut i Societat, Barcelona, España
| | - Antonia Arreciado Marañón
- Grup de Recerca Multidisciplinari en Salut i Societat, Barcelona, España; Departament d'Infermeria, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España
| | - Maria Feijoo-Cid
- Grup de Recerca Multidisciplinari en Salut i Societat, Barcelona, España; Departament d'Infermeria, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España
| | - Miquel Domènech
- Departament de Psicologia Social, Facultat de Psicologia, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España
| | - Lupicinio Íñiguez-Rueda
- Departament de Psicologia Social, Facultat de Psicologia, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España
| | - Núria Vallès-Peris
- Institut d'investigació en Intel·ligència Artificial, Consejo Superior de Investigaciones Científicas (IIIA-CSIC), Bellaterra (Cerdanyola del Vallès, Barcelona), España; Barcelona Science and Technology Studies Group (STS-b), Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès, Barcelona), España
| | | | - Pere Toran-Monserrat
- Unitat de Suport a la Recerca Metropolitana Nord, Institut Universitari d'Investigació en Atenció Primària Jordi Gol i Gurina, Mataró (Barcelona), España; Grup de Recerca Multidisciplinari en Salut i Societat, Barcelona, España
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Bastidas-Bilbao H, Castle D, Gupta M, Stergiopoulos V, Hawke LD. Medical assistance in dying for mental illness: a complex intervention requiring a correspondingly complex evaluation approach. Br J Psychiatry 2024:1-4. [PMID: 38433599 DOI: 10.1192/bjp.2024.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Medical assistance in dying for mental illness as a sole underlying medical condition (MAiD MI-SUMC) is a controversial and complex policy in terms of psychosocial and ethical medical practice implications. We discuss the status of MAiD MI-SUMC in Canada and argue for the use of the UK Medical Research Council's framework on complex interventions in programme evaluations of MAiD MI-SUMC. It is imperative to carefully and rigorously evaluate the implementation of MAiD MI-SUMC to ensure an understanding of the multiple facets of implementation in contexts permeated by unique social, economic, cultural and historical influences, with a correspondingly diverse array of outcomes. This requires a complexity-informed programme evaluation focused on context-dependent mechanisms and stakeholder experiences, including patients, service providers and other people affected by the policy. It is also important to consider the economic impact on health and social welfare systems. Such evaluations can provide the data needed to guide evidence-informed decision-making that can contribute to safer implementation and refinement of MAiD MI-SUMC.
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Affiliation(s)
- Hamer Bastidas-Bilbao
- Centre for Complex Interventions, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - David Castle
- Centre for Complex Interventions, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Mona Gupta
- Département de psychiatrie, Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Vicky Stergiopoulos
- Centre for Complex Interventions, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Lisa D Hawke
- Centre for Complex Interventions, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Scopetti M, Morena D, Padovano M, Manetti F, Di Fazio N, Delogu G, Ferracuti S, Frati P, Fineschi V. Assisted Suicide and Euthanasia in Mental Disorders: Ethical Positions in the Debate between Proportionality, Dignity, and the Right to Die. Healthcare (Basel) 2023; 11:healthcare11101470. [PMID: 37239756 DOI: 10.3390/healthcare11101470] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/27/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The admission of people suffering from psychiatric and neurocognitive disorders to euthanasia and physician-assisted suicide (E/PAS) in some European and non-European countries represents a controversial issue. In some countries, the initial limitation of E/PAS to cases of severe physical illness with poor prognosis in the short term has been overcome, as it was considered discriminatory; thus, E/PAS has also been made available to subjects suffering from mental disorders. This decision has raised significant ethical questions regarding the capacity and freedom of self-determination; the family, social, and economic contexts; the social consideration of the sense of dignity and the pressure on the judgment of one's personal value; the contextual therapeutic possibilities; the identification of figures involved in the validation and application; as well as the epistemological definitions of the clinical conditions in question. To these issues must be added the situation of legislative vacuum peculiar to different countries and the widespread lack of effective evaluation and control systems. Nonetheless, pessimistic indicators on global health status, availability of care and assistance, aging demographics, and socioeconomic levels suggest that there may be further pressure toward the expansion of such requests. The present paper aims to trace an international overview with the aim of providing ethical support to the debate on the matter. Precisely, the goal is the delimitation of foundations for clinical practice in the complex field of psychiatry between the recognition of the irreversibility of the disease, assessment of the state of physical and mental suffering, as well as the possibility of adopting free and informed choices.
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Affiliation(s)
- Matteo Scopetti
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy
| | - Donato Morena
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Martina Padovano
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Federico Manetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Giuseppe Delogu
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Stefano Ferracuti
- Department of Human Neuroscience, Sapienza University of Rome, 00185 Rome, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
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Trejo-Gabriel-Galán J. Eutanasias esperables en España según enfermedades y especialidades médicas. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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"Resource Limitation and 'Forced Irremediability' in Physician-Assisted Death for Nonterminal Mental and Physical Conditions: A Survey of the US Public". J Acad Consult Liaison Psychiatry 2022; 63:302-313. [PMID: 35026471 DOI: 10.1016/j.jaclp.2021.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/12/2021] [Accepted: 12/30/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Physician-assisted death (PAD) for people with nonterminal illnesses (PAD-NT) is a controversial practice legal in some countries and increasingly debated in others, including the US. A major concern about legalization of PAD-NT is that a lack of resources may drive some with mental illnesses or physical disabilities to seek PAD. METHODS The authors surveyed 2139 US adults matched to the US population in sex, age, race/ethnicity, education, political affiliation, and income. After giving their opinions regarding terminal PAD and PAD-NT in response to traditional PAD survey questions, respondents were randomly presented one of four scenarios of persons with nonterminal conditions requesting PAD-NT who lacked adequate resources to maintain their quality of life. The type of resources lacking (social or healthcare) and medical condition (mental or physical disability) were varied. Respondents' views regarding PAD-NT for the scenario specifically and legalization generally were then re-assessed. RESULTS At baseline, 55.4% of respondents supported legalizing terminal PAD and 36.9% supported legalizing PAD-NT. After scenarios, 28.2% (range 18.6% to 39.7%) agreed/strongly agreed with legalizing PAD-NT generally and 23.7% (15.2% to 33.7%) agreed/strongly agreed with PAD-NT for the instance depicted, with mental illness scenarios receiving much lower support; respondents' comments suggest devaluation of life with physical disability versus with mental illness. Being politically liberal, not religious, and assigned physical disability scenarios were associated with greater support for PAD-NT in multivariable analyses. CONCLUSIONS A minority of the US public supports PAD-NT in the context of inadequate resources, with much lower support for PAD-NT for mental illness than for physical disability, suggesting that PAD-NT policy debates and future research should address the issue of whether sufficient resources must be available to potential requestors of PAD-NT.
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Picón-Jaimes YA, Orozco-Chinome JE, Lozada-Martínez ID, Mass-Ramirez S, Higuera-Cetina CI, Montaña-Gómez LM, Moscote-Salazar LR, Narvaez-Rojas AR. Perception of Physicians Working in Chile Toward Assisted Suicide and Euthanasia: A Nationwide Cross-Sectional Study. J Prim Care Community Health 2022; 13:21501319221121462. [PMID: 36112863 PMCID: PMC9476241 DOI: 10.1177/21501319221121462] [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] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Assisted suicide and euthanasia are controversial issues today and have been throughout the history of humanity, mainly because there are individuals for and against them. Currently, the legalization of these practices is being discussed in Chile, and the perception of physicians regarding this issue is unknown. Therefore, this study aimed to assess physicians' perception of Chile's euthanasia and assisted suicide. METHODS A nationwide cross-sectional study was carried out in Chile. A questionnaire of physicians' attitudes and opinions on assisted suicide and euthanasia was used. The population was the doctors who work in Chile, and the sample was convenient with a sample calculation of 384 physicians. About 20 variables were considered and included in a form created through the Google forms option, which was distributed through social networks: LinkedIn, Facebook, Twitter, and WhatsApp. To guarantee the anonymity of the participants, the option to request and remember the participant's email was deactivated. A generated database allowed the quantitative analysis of the variables and their expression through frequencies, percentages, and graphs. The European University of the Atlantic's research ethics committee approved this study as stated in the document CE-55 of March 2021. RESULTS A total of 410 physicians were surveyed. 50.7% (n = 208) of the participants identified themselves as men, and 69.8% (n = 286) were Chilean. The city of Santiago was the area of residence of 72.9% (n = 299) of the participants. About 34.6% (n = 142) of participants were general practitioners, and 39.3% (n = 161) of the physicians had more than 20 years of experience. About 68.7% had favorable attitudes toward euthanasia and 54.4% toward assisted suicide; However, although the majority favored legalizing euthanasia and assisted suicide, approximately 48.8% stated that they would not participate in an assisted suicide procedure. CONCLUSIONS There was evidence of support for the implementation and legalization of euthanasia and assisted suicide by physicians in Chile. However, there are still professionals who have not yet decided on a definitive position on these practices.
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Affiliation(s)
| | | | - Iván David Lozada-Martínez
- International Coalition on Surgical Research, Bogotá, Colombia.,Universidad de Cartagena, Cartagena, Colombia
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Snijdewind MC, de Keijser J, Casteelen G, Boelen PA, Smid GE. "Only One Way Out"-Partners' Experiences and Grief Related to the Death of Their Loved One by Suicide or Physician-Assisted Dying Due to a Mental Disorder. Front Psychiatry 2022; 13:894417. [PMID: 35873257 PMCID: PMC9304962 DOI: 10.3389/fpsyt.2022.894417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Previous research has provided insight into the grief of suicide survivors, but little is known about grief following physician-assisted dying (PAD), and no prior study specifically focused on grief following PAD due to a mental disorder. The current study aims to increase insight into experiences preceding PAD or suicide of a loved one due to a mental disorder and their impact on mental health symptoms. METHODS We performed a survey study and in-depth interviews with 27 bereaved life partners. The deceased had been in treatment for mental disorders and had died by PAD (n = 12) or suicide (n = 15). Interviews explored grief experiences and experiences with mental health care. In the survey, we assessed self-reported symptoms of grief, post-traumatic stress, anxiety, depression, quality of life, and impairments in social, and occupational functioning. RESULTS All participants reported generally low levels of mental health symptoms. Longer time since death and death by PAD were associated with lower grief intensity. Interviews showed various degrees of expectedness of the partners' death, and a varying impact of being present at the death on bereaved partners. CONCLUSION Expectedness of the death of the partner, absence of suffering of the partner at the time of dying, and presence of physician support may in part explain the protective effects of PAD against severe grief reactions. Physicians considering their position regarding their personal involvement in PAD due to a mental disorder could take grief reactions of the bereaved partner into account.
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Affiliation(s)
- Marianne C Snijdewind
- ARQ Centrum'45, Diemen, Netherlands.,Department of Ethics, Law and Humanities, Amsterdam UMC, Academic Medical Centre, Amsterdam, Netherlands
| | - Jos de Keijser
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioral and Social Sciences, University of Groningen, Groningen, Netherlands
| | | | - Paul A Boelen
- ARQ Centrum'45, Diemen, Netherlands.,ARQ National Psychotrauma Centre, Diemen, Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
| | - Geert E Smid
- ARQ Centrum'45, Diemen, Netherlands.,ARQ National Psychotrauma Centre, Diemen, Netherlands.,Department of Humanistic Chaplaincy Studies, University of Humanistic Studies, Utrecht, Netherlands
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Debating Euthanasia and Physician-Assisted Death in People with Psychiatric Disorders. Curr Psychiatry Rep 2022; 24:325-335. [PMID: 35678920 PMCID: PMC9203391 DOI: 10.1007/s11920-022-01339-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Over the last 30 years, medical assistance in dying (MAiD) including euthanasia (EU) and physician-assisted death (or suicide, PAS) has become the center of a large debate, particularly when these practices have involved people with psychiatric illness, including resistant depression, schizophrenia, personality, or other severe psychiatric disorders. We performed a review utilizing several databases, and by including the most relevant studies in full journal articles investigating the problem of MAiD in patients with psychiatric disorders but not in physical terminal conditions (non-terminal, MAiD-NT). RECENT FINDINGS Literature has shown that a small percentage of people with psychiatric disorders died by MAiD-NT in comparison with patients with somatic diseases in terminal clinical conditions (e.g., cancer, AIDS). However, the problem in the field is complex and not solved yet as confirmed by the fact that only a few countries (e.g., the Netherlands, Belgium, Luxemburg) have legalized MAiD-NT for patients with psychiatric disorders, while most have maintained the practices accessible only to people with somatic disease in a terminal phase. Also, how to make objective the criterion of irremediability of a mental disorder; how to balance suicide prevention with assisted suicide; how to avoid the risk of progressively including in requests for MAiD-NT vulnerable segments of the population, such as minors, elderly, or people with dementia, in a productive-oriented society, are some of the critical points to be discussed. The application of MAiD-NT in people with psychiatric disorders should be further explored to prevent end-of-life rights from contradicting the principles of recovery-oriented care.
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Pronk R, Willems DL, van de Vathorst S. What About Us? Experiences of Relatives Regarding Physician-Assisted Death for Patients Suffering from Mental Illness: A Qualitative Study. Cult Med Psychiatry 2021; 47:237-251. [PMID: 34914019 PMCID: PMC8674522 DOI: 10.1007/s11013-021-09762-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 01/01/2023]
Abstract
Physician-assisted death (PAD) for patients suffering from mental illness is legally permitted in the Netherlands. Although patients' relatives are not entrusted with a legal role, former research revealed that physicians take into account the patient's social context and their well-being, in deciding whether or not to grant the request. However, these studies focussed on relatives' experiences in the context of PAD concerning patients with somatic illness. To date, nothing is known on their experiences in the context of PAD concerning the mentally ill. We studied the experiences of relatives with regard to a PAD request by patients suffering from mental illness. The data for this study were collected through 12 interviews with relatives of patients who have or had a PAD request because of a mental illness. We show that relatives are ambivalent regarding the patient's request for PAD and the following trajectory. Their ambivalence is characterised by their understanding of the wish to die and at the same time hoping that the patient would make another choice. Respondents' experiences regarding the process of the PAD request varied, from positive ('intimate') to negative ('extremely hard'). Some indicated that they wished to be more involved as they believe the road towards PAD should be a joint trajectory. To leave them out during such an important event is not only painful, but also harmful to the relative as it could potentially complicate their grieving process. Professional support during or after the PAD process was wanted by some, but not by all.
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Affiliation(s)
- Rosalie Pronk
- Department of Ethics, Law and Humanities, Amsterdam UMC, Academic Medical Centre, Room J2-126, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - D. L. Willems
- Department of Ethics, Law and Humanities, Amsterdam UMC, Academic Medical Centre, Room J2-126, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - S. van de Vathorst
- Department of Ethics, Law and Humanities, Amsterdam UMC, Academic Medical Centre, Room J2-126, PO Box 22660, 1100 DD Amsterdam, The Netherlands ,Department of Medical Ethics and Philosophy, Erasmus Medical Centre, Rotterdam, The Netherlands
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Trejo-Gabriel-Galán JM. Expected euthanasias in Spain according to diseases and medical specialties. Rev Clin Esp 2021; 222:192-193. [PMID: 34862153 DOI: 10.1016/j.rceng.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022]
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12
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Schmahl O, Oude Voshaar R, van de Poel-Mustafayeva A, Marijnissen R. Request for euthanasia by a psychiatric patient with undetected intellectual disability. BMJ Case Rep 2021; 14:e239862. [PMID: 34404641 PMCID: PMC8375729 DOI: 10.1136/bcr-2020-239862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2021] [Indexed: 11/04/2022] Open
Abstract
In the Netherlands, euthanasia or assisted suicide (EAS) in psychiatric disorders is legal in certain circumstances. Guidelines recommend a second opinion to independently check diagnosis and treatment resistance. A 68-year-old patient, diagnosed with bipolar I disorder, with a request for euthanasia because of tiredness, repeated falls and racing thoughts was seen for such a second opinion. Persisting in her wish, her reluctant family and psychiatrist became convinced of euthanasia. Our disagreement with the diagnosis of bipolar I disorder upset her, but she agreed with discontinuation of psychotropic drugs. Her mobility and tiredness improved, whereafter her request for euthanasia evolved into a death wish due to completed life. Intellectual disability and an attention deficit hyperactivity disorder could explain her struggle in life. This case report shows that extending the procedure regarding EAS with an independent psychiatric evaluation is important. For our patient, this second opinion supported her to find meaning in life.
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Affiliation(s)
- Olga Schmahl
- University Center for Psychiatry, University Medical Centre Groningen, Groningen, The Netherlands
| | - Richard Oude Voshaar
- University Center for Psychiatry, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Radboud Marijnissen
- University Center for Psychiatry, University Medical Centre Groningen, Groningen, The Netherlands
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Pronk R, Sindram NP, van de Vathorst S, Willems DL. Experiences and views of Dutch general practitioners regarding physician-assisted death for patients suffering from severe mental illness: a mixed methods approach. Scand J Prim Health Care 2021; 39:166-173. [PMID: 34241574 PMCID: PMC8293937 DOI: 10.1080/02813432.2021.1913895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 01/25/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In the Netherlands, physician-assisted death (PAD) is allowed under certain conditions. Patients who suffer from mental illnesses are not excluded from this practice. In 2018, general practitioners (GPs) performed 20 out of a total of 67 cases of EAS for psychiatric suffering. OBJECTIVE More insight into GPs' experiences and views with regard to PAD in psychiatry. DESIGN The data for this study were obtained through a survey amongst 500 randomly selected Dutch GPs and by in-depth interviews with 20 Dutch GPs. SETTING A survey study and in-depth interviews. SUBJECTS Dutch GPs. RESULTS 86 out of 101 GPs found it conceivable to perform EAS in case of somatic disease, and 51 out of 104 GPs found it conceivable in the case a patient suffered from a mental illness only. The main reason given for refusing an PAD request was that the criteria of due care were not met. Reasons for supporting psychiatric PAD related to responsibility, self-determination, compassion, fairness, and preventing suicide. Reasons for not supporting psychiatric PAD were related to the scope of medicine, a perceived lack of experience, uncertainties regarding the criteria of due care and life-expectancy. CONCLUSION GPs are less likely to perform PAD for suffering from a mental illness, compared to somatic suffering. Some GPs apply an extra criterion of 'life-expectancy' in case of PAD for suffering from a mental illness. Refusing PAD based on a long life expectancy keeps open the possibility of recovery, but may also just prolong the suffering and add to the unbearableness of it.KEY POINTSCurrently, there is no qualitative research on what the views are of general practitioners regarding the subject of physician-assisted death (PAD) for patients suffering from severe mental disorders.General practitioners are less likely to consider a request for physician-assisted death by a patient suffering from a psychiatric disorder, compared to somatic suffering. Reasons for supporting psychiatric PAD related to responsibility, self-determination, compassion, fairness, and preventing suicide.Reasons for not supporting psychiatric PAD were related to the scope of medicine, a perceived lack of experience, uncertainties regarding the criteria of due care and life-expectancy.Significance for the reader: Although allowed in the Netherlands, PAD in case of severe mental suffering remains a controversial topic. We need in-depth information about the actual practice of it to have an informed debate with regard to this subject.
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Affiliation(s)
- Rosalie Pronk
- Department of General Practice, Medical Ethics Section, Amsterdam UMC, Academic Medical Centre, Amsterdam, The Netherlands
| | - Nieke P. Sindram
- Department of General Practice, Medical Ethics Section, Amsterdam UMC, Academic Medical Centre, Amsterdam, The Netherlands
| | - S. van de Vathorst
- Department of General Practice, Medical Ethics Section, Amsterdam UMC, Academic Medical Centre, Amsterdam, The Netherlands
- Department of Medical Ethics and Philosophy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - D. L. Willems
- Department of General Practice, Medical Ethics Section, Amsterdam UMC, Academic Medical Centre, Amsterdam, The Netherlands
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Pronk R, Willems DL, van de Vathorst S. Do Doctors Differentiate Between Suicide and Physician-Assisted Death? A Qualitative Study into the Views of Psychiatrists and General Practitioners. Cult Med Psychiatry 2021; 45:268-281. [PMID: 32833142 PMCID: PMC8110501 DOI: 10.1007/s11013-020-09686-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Physician-assisted death for patients suffering from psychiatric disorders is allowed in the Netherlands under certain circumstances. One of the central problems that arise with regard to this practice is the question of whether it is possible to distinguish between suicidality and a request for physician-assisted death. We set up this study to gain insight into how psychiatrists and general practitioners distinguish between suicidality and physician-assisted death. The data for this study were collected through qualitative interviews with 20 general practitioners and 17 psychiatrists in the Netherlands. From the interviews, we conclude that physicians distinguish three types of death wishes among patients suffering from psychiatric disorders: 'impulsive suicidality,' 'chronic suicidality,' and 'rational death wishes.' To discern between them they evaluate whether the death wish is seen as part of the psychopathology, whether it is consistent over time, and whether they consider it treatable. Some considered physician-assisted death an alternative to a 'rational suicide,' as this was perceived to be a more humane manner of death for the patient and their relatives. We argue that physician-assisted death can be justified also in some cases in which the death wish is part of the psychopathology, as the patient's suffering can be unbearable and irremediable. Physician-assisted death in these cases may remain the only option left to relieve the suffering.
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Affiliation(s)
- Rosalie Pronk
- Department of General Practice, Medical Ethics Section, Academic Medical Centre, Amsterdam UMC, Amsterdam, The Netherlands.
- Department of General Practice, Medical Ethics Section, Academic Medical Centre, Amsterdam UMC, Room J2-219, PO Box 22660, Amsterdam, The Netherlands.
| | - Dick L Willems
- Department of General Practice, Medical Ethics Section, Academic Medical Centre, Amsterdam UMC, Amsterdam, The Netherlands
| | - Suzanne van de Vathorst
- Department of General Practice, Medical Ethics Section, Academic Medical Centre, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Medical Ethics and Philosophy, Erasmus Medical Centre, Rotterdam, The Netherlands
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15
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Brinkman-Stoppelenburg A, Evenblij K, Pasman HRW, van Delden JJM, Onwuteaka-Philipsen BD, van der Heide A. Physicians' and Public Attitudes Toward Euthanasia in People with Advanced Dementia. J Am Geriatr Soc 2020; 68:2319-2328. [PMID: 32652560 PMCID: PMC7689700 DOI: 10.1111/jgs.16692] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/15/2020] [Accepted: 06/04/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND/OBJECTIVES To explore the opinion of the Dutch general public and of physicians regarding euthanasia in patients with advanced dementia. DESIGN A cross‐sectional survey. SETTING The Netherlands. PARTICIPANTS Random samples of 1,965 citizens (response = 1,965/2,641 [75%]) and 1,147 physicians (response = 1,147/2,232 [51%]). MEASUREMENTS The general public was asked to what extent they agreed with the statement “I think that people with dementia should be eligible for euthanasia, even if they no longer understand what is happening (if they have previously asked for it).” Physicians were asked whether they were of the opinion that performing euthanasia is conceivable in patients with advanced dementia, on the basis of a written advance directive, in the absence of severe comorbidities. Multivariable logistic regression was performed to identify factors associated with the acceptance of euthanasia. RESULTS A total of 60% of the general public agreed that people with advanced dementia should be eligible for euthanasia. Factors associated with a positive attitude toward euthanasia were being female, age between 40 and 69 years, and higher educational level. Considering religion important was associated with lower acceptance. The percentage of physicians who considered it acceptable to perform euthanasia in people with advanced dementia was 24% for general practitioners, 23% for clinical specialists, and 8% for nursing home physicians. Having ever performed euthanasia before was positively associated with physicians considering euthanasia conceivable. Being female, having religious beliefs, and being a nursing home physician were negatively associated with regarding performing euthanasia as conceivable. CONCLUSION There is a discrepancy between public acceptance of euthanasia in patients with advanced dementia and physicians' conceivability of performing euthanasia in these patients. This discrepancy may cause tensions in daily practice because patients' and families' expectations may not be met. It urges patients, families, and physicians to discuss mutual expectations in these complex situations in a comprehensive and timely manner. J Am Geriatr Soc 68:2319–2328, 2020.
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Affiliation(s)
| | - Kirsten Evenblij
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H Roeline W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Johannes J M van Delden
- Julius Centrum voor Gezondheidswetenschappen en Eerstelijnsgeneeskunde, UMCU, Utrecht, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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16
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Roest B. Old problems in need of new (narrative) approaches? A young physician-bioethicist's search for ethical guidance in the practice of physician-assisted dying in the Netherlands. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2019-106016. [PMID: 32376718 DOI: 10.1136/medethics-2019-106016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/10/2020] [Accepted: 04/16/2020] [Indexed: 06/11/2023]
Abstract
The current empirical research and normative arguments on physician-assisted dying (PAD) in the Netherlands seem insufficient to provide ethical guidance to general practitioners in the practice of PAD, due to a gap between the evidence and arguments on the one hand and the uncertainties and complexities as found in everyday practice on the other. This paper addresses the problems of current ethical arguments and empirical research and how both seem to be profoundly influenced by the Dutch legislative framework on PAD and a certain view on ethics. Furthermore, the paper elaborates on how other approaches to empirical research in bioethics, such as found in the broad field of narrative research, could supplement the empirical and ethical evaluation of PAD in the Netherlands. This paper also addresses the challenging question of how empirical data-in this case narratives-relate to normativity. The paper is written in the form of a personal narrative of the author, a young Dutch general practitioner and researcher in bioethics. This style is intentionally chosen, to illustrate how work context and professional background influence the observations one makes and the questions one may ask about the topic of PAD. In addition, by using this style, this paper not only gives a different perspective on a much-contested bioethical issue, but also on the challenges faced when a physician-bioethicist has to navigate different disciplinary fields and (moral) epistemological paradigms, especially since the 'empirical turn' in bioethics.
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Affiliation(s)
- Bernadette Roest
- Department of Care Ethics, University of Humanistic Studies, Utrecht, The Netherlands
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