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Archer M, Willmott L, Chambaere K, Deliens L, White BP. Mapping Sources of Assisted Dying Regulation in Belgium: A Scoping Review of the Literature. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231210146. [PMID: 37914208 DOI: 10.1177/00302228231210146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Belgium has over 20 years of experience regulating assisted dying (AD). While much research considers this end-of-life practice, no studies have comprehensively analysed the various sources of regulation that govern it, including law, professional standards, and ethics. A scoping review identified all sources of regulation that guide AD practice, and their regulatory functions. Databases and reference lists were searched for records which met inclusion criteria between 11/2/22 and 25/3/22. Existing scholarship was used to identify sources of regulation, and thematically analyse their functions. Of the initial sample of 1364 records, 107 were included. Six sources of regulation were identified: law, policies, professional standards, training, advisory documents, and system design. Three regulatory functions were identified: prescribing conduct, scaffolding to support practice, and monitoring the system. The Belgian AD regulatory framework is multifaceted, complex, and fragmented. Providers must navigate and reconcile numerous sources of guidance providing this form of end-of-life care.
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Affiliation(s)
- Madeleine Archer
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
- Department of Public Health & Primary Care, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
- Department of Public Health & Primary Care, Ghent University, Ghent, Belgium
| | - Ben P White
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, QLD, Australia
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Rawlings D, Winsall M, Miller-Lewis L, Tieman J. Natural Death Versus Known Date-Of-Death: A Qualitative Study of Views on Voluntary Assisted Dying in an Online Course About Death. OMEGA-JOURNAL OF DEATH AND DYING 2023; 86:1272-1290. [PMID: 33840272 DOI: 10.1177/00302228211008771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The study aimed to describe views on Voluntary Assisted Dying (VAD), gleaned through qualitative analysis of participant responses to a set activity, run during the 2018 'Dying2Learn' Massive Open Online Course (MOOC). Data from 508 participants, most of whom identified as health professionals, were analysed using thematic content analysis, and themes generated. A large proportion of participants discussed their personal views related to VAD, specifically around choice, control, dignity, palliative care and dying at home, medical intervention, societal factors, the impact on those left behind, laws and regulations, dying 'naturally', advance care directives, and being in pain. In this study, participants had many different views on the act itself, often divisive, but also with common concepts such as respecting the choices and decisions of others.
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Affiliation(s)
- Deb Rawlings
- Palliative & Supportive Services, Flinders University, Bedford Park, Australia
| | - Megan Winsall
- Palliative & Supportive Services, Flinders University, Bedford Park, Australia
| | - Lauren Miller-Lewis
- School of Health, Medical and Applied Sciences, CQUniversity, Adelaide, Australia
| | - Jennifer Tieman
- Palliative & Supportive Services, Flinders University, Bedford Park, Australia
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Tang F, Tang Z, Lu Z, Cai Y, Lai Y, Mai Y, Li Z, Lu Z, Zhang J, Li Z, He Z. A novel autophagy-related long non-coding RNAs prognostic risk score for clear cell renal cell carcinoma. BMC Urol 2022; 22:203. [PMID: 36496360 PMCID: PMC9741795 DOI: 10.1186/s12894-022-01148-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 11/08/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND As the main histological subtype of renal cell carcinoma, clear cell renal cell carcinoma (ccRCC) places a heavy burden on health worldwide. Autophagy-related long non-coding RNAs (ARlncRs) have shown tremendous potential as prognostic signatures in several studies, but the relationship between them and ccRCC still has to be demonstrated. METHODS The RNA-sequencing and clinical characteristics of 483 ccRCC patients were downloaded download from the Cancer Genome Atlas and International Cancer Genome Consortium. ARlncRs were determined by Pearson correlation analysis. Univariate and multivariate Cox regression analyses were applied to establish a risk score model. A nomogram was constructed considering independent prognostic factors. The Harrell concordance index calibration curve and the receiver operating characteristic analysis were utilized to evaluate the nomogram. Furthermore, functional enrichment analysis was used for differentially expressed genes between the two groups of high- and low-risk scores. RESULTS A total of 9 SARlncRs were established as a risk score model. The Kaplan-Meier survival curve, principal component analysis, and subgroup analysis showed that low overall survival of patients was associated with high-risk scores. Age, M stage, and risk score were identified as independent prognostic factors to establish a nomogram, whose concordance index in the training cohort, internal validation, and external ICGC cohort was 0.793, 0.671, and 0.668 respectively. The area under the curve for 5-year OS prediction in the training cohort, internal validation, and external ICGC cohort was 0.840, 0.706, and 0.708, respectively. GO analysis and KEGG analysis of DEGs demonstrated that immune- and inflammatory-related pathways are likely to be critically involved in the progress of ccRCC. CONCLUSIONS We established and validated a novel ARlncRs prognostic risk model which is valuable as a potential therapeutic target and prognosis indicator for ccRCC. A nomogram including the risk model is a promising clinical tool for outcomes prediction of ccRCC patients and further formulation of individualized strategy.
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Affiliation(s)
- Fucai Tang
- grid.12981.330000 0001 2360 039XDepartment of Urology, The Eighth Affiliated Hospital, Sun Yat-Sen University, No. 3025, Shennan Zhong Road, Shenzhen, 518033 China
| | - Zhicheng Tang
- grid.410737.60000 0000 8653 1072The Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, 511436 Guangdong China
| | - Zechao Lu
- grid.12981.330000 0001 2360 039XDepartment of Urology, The Eighth Affiliated Hospital, Sun Yat-Sen University, No. 3025, Shennan Zhong Road, Shenzhen, 518033 China
| | - Yueqiao Cai
- grid.410737.60000 0000 8653 1072The First Clinical College of Guangzhou Medical University, Guangzhou, 511436 Guangdong China
| | - Yongchang Lai
- grid.12981.330000 0001 2360 039XDepartment of Urology, The Eighth Affiliated Hospital, Sun Yat-Sen University, No. 3025, Shennan Zhong Road, Shenzhen, 518033 China
| | - Yuexue Mai
- grid.410737.60000 0000 8653 1072The Sixth Clinical College of Guangzhou Medical University, Guangzhou, 511436 Guangdong China
| | - Zhibiao Li
- grid.12981.330000 0001 2360 039XDepartment of Urology, The Eighth Affiliated Hospital, Sun Yat-Sen University, No. 3025, Shennan Zhong Road, Shenzhen, 518033 China
| | - Zeguang Lu
- grid.410737.60000 0000 8653 1072The Second Clinical College of Guangzhou Medical University, Guangzhou, 511436 Guangdong China
| | - Jiahao Zhang
- grid.410737.60000 0000 8653 1072The Sixth Clinical College of Guangzhou Medical University, Guangzhou, 511436 Guangdong China
| | - Ze Li
- grid.410737.60000 0000 8653 1072The First Clinical College of Guangzhou Medical University, Guangzhou, 511436 Guangdong China
| | - Zhaohui He
- grid.12981.330000 0001 2360 039XDepartment of Urology, The Eighth Affiliated Hospital, Sun Yat-Sen University, No. 3025, Shennan Zhong Road, Shenzhen, 518033 China
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Medical practitioners' views and experiences of being involved in assisted dying in Victoria, Australia: A qualitative interview study among participating doctors. Soc Sci Med 2021; 292:114568. [PMID: 34801335 DOI: 10.1016/j.socscimed.2021.114568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/18/2021] [Accepted: 11/13/2021] [Indexed: 11/24/2022]
Abstract
RATIONALE On June 19, 2019, Assisted Dying (AD) was legalized in the Australian state of Victoria, joining a small but growing cohort of jurisdictions internationally where AD is permitted. Few studies have examined perspectives of doctors who have participated in AD in jurisdictions where it has become legal, despite their pivotal role in the system. OBJECTIVE This study aimed to describe the beliefs, experiences and perspectives of doctors who had provided AD during the first 12 months of its operation in Victoria, Australia. METHOD In-depth, semi-structured interviews were conducted between April and July 2020 with 32 Victorian doctors who had been involved in the AD process during the first 12-months since it became legal in Victoria. The assumptions underpinning our methodology were guided by a phenomenological approach and reflexive thematic analysis was used to analyze the data. RESULTS Five major themes were identified: a nascent approach to care, practising within clinical and legal uncertainty, confronting practices, personal sacrifices and coping amid new challenges. A thematic schema was developed, illustrating that these themes were expressed as a balance of competing tensions of identity for doctors who provided AD for their patients in practice. A major tension was not just how doctors' perceptions impacted their own wellbeing and satisfaction, but also how these challenged their continued involvement in AD and, therefore, the system's overall ability to function. CONCLUSION Our findings show that while doctors discussed AD as an ethical practice, it also involved multiple identities with varying sources of meaning, and these identities were sometimes overlapping depending on context. As other jurisdictions increasingly move to legalize AD, a greater appreciation of the different role-based and group-based challenges involved in AD may improve AD implementation strategies.
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Sellars M, Tacey M, McDougall R, Hayes B, Pratt B, Hempton C, Detering K, Aldrich R, Benson M, Kirwan J, Gold M, O'Driscoll L, Ko D. Support for and willingness to be involved in voluntary assisted dying: A multisite, cross-sectional survey study of clinicians in Victoria, Australia. Intern Med J 2021; 51:1619-1628. [PMID: 34148272 DOI: 10.1111/imj.15434] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
CONTEXT In the Australian state of Victoria, specialist doctors are central to the operation of Voluntary Assisted Dying (VAD). However, a broad range of clinicians may be involved in the care of patients requesting or using VAD. OBJECTIVES To conduct a multisite, cross-sectional survey of clinicians in seven Victorian hospitals, to describe levels of support for and willingness to be involved in VAD and consider factors associated with clinician support for the VAD legislation and physicians' willingness to provide VAD in practice. METHODS All clinicians were invited to complete an online survey measuring demographic characteristics, awareness of and support for the VAD legislation, willingness to participate in VAD related activities, and reasons for willingness or unwillingness to participate in VAD. RESULTS Of 5690 who opened the survey, 5159 (90.1%) were included in the final sample and 73% (n=3768) supported the VAD legislation. The strongest predictor of support for the VAD legislation was clinical role. Forty percent (n=238) of medical specialists indicated they would be willing to participate in either the VAD consulting or coordinating role. Doctors did not differ in willingness between high impact (44%) and low impact specialty (41%), however, doctors specializing in palliative care or geriatric medicine were significantly less willing to participate (27%). CONCLUSION Approximately 73% of surveyed staff supported Victoria's VAD legislation. However, only a minority of medical specialists reported willingness to participate in VAD, suggesting potential access issues for patients requesting VAD in accordance with the legal requirements in Victoria. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Marcus Sellars
- Department of Health Services Research and Policy, Research School of Population Health, Australian National University
| | - Mark Tacey
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Rosalind McDougall
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Barbara Hayes
- Advance Care Planning Program, Northern Health, Bundoora, Australia
| | - Bridget Pratt
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Courtney Hempton
- Alfred Deakin Institute for Citizenship and Globalisation, Deakin University, Waurn Ponds, Australia.,Monash Bioethics Centre, Monash University, Clayton, Australia
| | - Karen Detering
- Faculty of Health, Arts and Innovation, Swinburne University, Hawthorn, Melbourne, Australia.,Tasmanian Health Services, Tasmania, Australia
| | | | - Melanie Benson
- Department of Supportive and Palliative Care, Peninsula Health, Frankston
| | - Jeffrey Kirwan
- Research & Medical Services, Eastern Health, Box Hill, Australia
| | - Michelle Gold
- Palliative Care Service, Alfred Health, Prahran, Australia
| | - Lisa O'Driscoll
- 3mproving End of Life Care, Alfred Health, Prahran, Australia
| | - Danielle Ko
- Palliative Care, Quality and Patient Safety, Austin Health, Heidelberg, Australia
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White BP, Willmott L, Sellars M, Yates P. Prospective oversight and approval of assisted dying cases in Victoria, Australia: a qualitative study of doctors' perspectives. BMJ Support Palliat Care 2021:bmjspcare-2021-002972. [PMID: 34092550 DOI: 10.1136/bmjspcare-2021-002972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Assisted dying (AD) is increasingly becoming lawful internationally. While all AD models have oversight mechanisms, Victoria, Australia is rare in requiring formal approval before AD is permitted. Other jurisdictions are now enacting or implementing prospective approval models yet little is known about their operation. This paper reports the first empirical research internationally analysing the operation of a prospective approval model. METHODS This qualitative study recruited doctors involved in providing lawful AD during the first year of the Victorian AD system. Recruitment occurred through the mandatory training doctors providing AD must undertake. Semistructured interviews were undertaken predominantly through Zoom conferencing, transcribed and thematically analysed. RESULTS 32 doctors from diverse specialties (including general practice) and diverse AD experiences were interviewed. Six themes were identified: (1) The primary gatekeeping to AD in practice was by the administrative Secretariat of the oversight body, the Voluntary Assisted Dying Review Board, and not the government department who issues the final 'permit'; this may not have been intended by parliament. (2) The prospective oversight and approval process was bureaucratic and (3) the mandatory online system to manage AD was a barrier. (4) These factors caused unnecessary delays which (5) impeded AD for very sick patients. (6) However, this prospective process protected doctors and ensured system safety. CONCLUSIONS Potential barriers to accessing AD posed by prospective approval should be evaluated carefully by jurisdictions implementing or considering such a model. Attention is needed not only to law but to system design and how AD is implemented in practice.
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Affiliation(s)
- Ben P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Marcus Sellars
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Patsy Yates
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
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O'Connor M, Mandel C, Mewett G, Catford Dch J, McMaugh J. Implementing voluntary assisted dying in Victoria, Australia. Int J Health Plann Manage 2021; 36:602-609. [PMID: 33591588 DOI: 10.1002/hpm.3126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 11/08/2022] Open
Abstract
This paper describes the process undertaken to implement voluntary assisted dying (VAD) in Victoria, Australia. While the Bill became law in December 2017, an 18-month implementation period was allocated to anticipate the clinical complexities of how VAD would occur in various settings, requiring an exhaustive process to address the significant changes required of health services.Implementation involved detailed health planning, and the process included a large range of health practitioners and community members, keeping a close eye to the complementarity of the various pieces of work, as well as the many safeguards required.Written from the perspective of those involved in planning the implementation, it is hoped that articulating this Victorian experience will assist others. Implementation is a complex process and takes time; it must be broadly collaborative and reflective, to ensure both health professionals and community members understand the legislative changes, as well as the responses required.
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Affiliation(s)
- Margaret O'Connor
- Department of Nursing & Midwifery, Monash University, Frankston, Victoria, Australia.,Melbourne City Mission Palliative Care North Fitzroy, Fitzroy North, Victoria, Australia
| | - Catherine Mandel
- Swinburne Neuroimaging, School of Health Sciences, Faculty of Health Arts and Design, Swinburne University of Technology, Hawthorn, Victoria, Australia
| | - Greg Mewett
- Palliative Care Unit, Ballarat Health Service, Palliative Care, Ballarat, Victoria, Australia
| | - John Catford Dch
- Faculty of Health, Deakin University Burwood, Burwood, Victoria, Australia.,Epworth Health, Richmond, Victoria, Australia
| | - Jarrod McMaugh
- Pharmaceutical Society of Australia, Melbourne, Victoria, Australia
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McDougall R, Pratt B. Too much safety? Safeguards and equal access in the context of voluntary assisted dying legislation. BMC Med Ethics 2020; 21:38. [PMID: 32404097 PMCID: PMC7222560 DOI: 10.1186/s12910-020-00483-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/05/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In June 2019, the Australian state of Victoria joined the growing number of jurisdictions around the world to have legalised some form of voluntary assisted dying. A discourse of safety was prominent during the implementation of the Victorian legislation. MAIN TEXT In this paper, we analyse the ethical relationship between legislative "safeguards" and equal access. Drawing primarily on Ruger's model of equal access to health care services, we analyse the Victorian approach to voluntary assisted dying in terms of four dimensions: horizontal equity, patient agency, high quality care, and supportive social norms. We argue that some provisions framed as safeguards in the legislation create significant barriers to equal access for eligible patients. CONCLUSIONS While safety is undoubtedly ethically important, we caution against an overemphasis on safeguarding in voluntary assisted dying legislation given the implications for equal access.
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Affiliation(s)
- Rosalind McDougall
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Level 4, 207 Bouverie St, Melbourne, VIC, 3010, Australia.
| | - Bridget Pratt
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Level 4, 207 Bouverie St, Melbourne, VIC, 3010, Australia
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