Are general practitioners prepared to end life on request in a country where euthanasia is legalised?

BACKGROUND

In 2002, Belgium set a legal framework for euthanasia, whereby granting and performing euthanasia is entrusted entirely to physicians, and-as advised by Belgian Medical Deontology--in the context of a trusted patient--physician relationship. Euthanasia is, however, rarely practiced, so the average physician will not attain routine in this matter.

AIM

To explore how general practitioners in Flanders (Belgium) deal with euthanasia. This was performed via qualitative analysis of semistructured interviews with 52 general practitioners (GPs).

RESULTS

Although GPs can understand a patient's request for euthanasia, their own willingness to perform it is limited, based on their assumption that legal euthanasia equates to an injection that ends life abruptly. Their willingness to perform euthanasia is affected by the demanding nature of a patient's request, by their views on what circumstances render euthanasia legitimate and by their own ability to inject a lethal dose. Several GPs prefer increasing opioid dosages and palliative sedation to a lethal injection, which they consider to fall outside the scope of euthanasia legislation.

CONCLUSIONS

Four attitudes can be identified: (1) willing to perform euthanasia; (2) only willing to perform as a last resort; (3) feeling incapable of performing; (4) refusing on principle. The situation where GPs have to consider the request and-if they grant it-to perform the act may result in arbitrary access to euthanasia for the patient. The possibility of installing transparent referral and support strategies for the GPs should be further examined. Further discussion is needed in the medical profession about the exact content of the euthanasia law.

[Decision-making and end of life care]

Taboos surrounding the end of life and death slowly diminish. People talk more and more about when and how they want or do not want to die, and of what will become of their body after their passing. General practitioners usually accompany their patients in illness and health, but also when death comes near. It is expected from them that, within their relationship to their patients, they create the opportunity to address the patients' last wishes and possibly to formalize them. Three laws as well as the Deontology Code of the Medical Order mention the issue of the last wishes. What comes out is that for the general practitioner, the situation is not always transparent. This article seeks to clarify the definitions (juridical), their perceptions and respect. Furthermore, a proposal that is fully in the spirit of the law is made to simplify current procedures relating to anticipated statements about end of life's wishes.

[Decision-making processes and medical care at the end of life]

The Federal Authority, the Ministry of Public Health and Environment, charged the Ghent University and the Brussels Free University to produce a continuous recording tool of data's concerning the decision-making processes and the medical care at the end of life, after defining the present state of the art. This tool is built up from a glossary and a questionnaire made up of closed questions with a prospective part and a retrospective part, and leaving the possibility of comments. This questionnaire, first submit to experts and two ethic committees, was sent anonymously to a broad sample of doctors of which 193 answered. This study brings out important information on the application of the laws on palliative care, on the rights of the patient and on euthanasia; it would be advisable to organise in the future a further systematic recording of the end of life conditions throughout a standardized questionnaire whose first version is presented here.

Socio-economic status of the patient and doctor-patient communication: does it make a difference?

This systematic review, in which 12 original research papers and meta-analyses were included, explored whether patients' socio-economic status influences doctor-patient communication. Results show that patients from lower social classes receive less positive socio-emotional utterances and a more directive and less participatory consulting style, characterised by significantly less information giving, less directions and less socio-emotional and partnership building utterances from their doctor. Doctors' communicative style is influenced by the way patients communicate: patients from higher social classes communicate more actively and show more affective expressiveness, eliciting more information from their doctor. Patients from lower social classes are often disadvantaged because of the doctor's misperception of their desire and need for information and their ability to take part in the care process. A more effective communication could be established by both doctors and patients through doctors' awareness of the contextual communicative differences and empowering patients to express concerns and preferences.

Communication in general practice: differences between European countries

BACKGROUND

Based on differences in national health care system characteristics such as the gatekeeping role of GPs (at the macrolevel) and on diverging GP and patient characteristics (at the microlevel), communication may differ between countries. Knowledge of the influence of these characteristics on doctor-patient communication will be important for setting European health care policies.

OBJECTIVES

Our objectives were (i) to compare doctor-patient communication in general practice between European countries; and (ii) to investigate the influence of the gatekeeping system and GP and patient characteristics on doctor-patient communication in general practice.

METHODS

Fifteen patients per GP (in total 2825 patients) of 190 GPs in six European countries were included. Participating countries were The Netherlands, Spain, the UK (gatekeeping countries), Belgium, Germany and Switzerland (non-gatekeeping countries). Data were collected by means of patient and GP questionnaires and observation of videotaped consultations, and analysed by one-way and multilevel, multivariate analysis.

RESULTS

Differences in communication between countries were found in: affective and instrumental behaviour; biomedical and psychosocial talk; GPs' patient-directed gaze; and consultation length. The study showed that GPs' gatekeeping role (with registered patients) was less important for doctor-patient communication than was expected. Patient characteristics such as gender, age, having psychosocial problems, and familiarity between the doctor and the patient were the most important in explaining differences in communication.

CONCLUSION

The gatekeeping role of GPs is hardly important in explaining doctor-patient communication. The relationship is more complex than expected. Patient and GP characteristics are more important. Cultural factors should be included in future studies.

Is GP-patient communication related to their perceptions of illness severity, coping and social support?

The aim of the study was to explore the relationship between the communicative behaviour of general practitioner and patient on the one hand and the perception of the coping behaviour of the patient, the severity of the complaint and the presence of social support on the other hand. From 20 general practitioners (GP), 15 consultations per GP were videotaped and analysed using the Roter Interaction Analysis System. Doctors and patients rated their perceptions on questionnaires. The finding was that doctors and patients used predominantly task-oriented (instrumental) behaviour, with some exceptions. With older patients and patients with low social support the GPs used more affective communication, mainly consisting of social talk and mutual agreement. In the case of complex problems, the GP paid special attention to the relationship with the patient. Within the domain of instrumental communication, some differences between doctor and patient were observed. Although doctors and patients exchanged a lot of information about medical issues, patients gave information about their lifestyle and emotions, which the doctors did not verbally explore. In consultations where the patient perceived the complaint as severe, he or she was more focussed on the medical content. When the GP considered psychosocial issues important, doctor and patient communicated about lifestyle, emotions and social relations. This doctor-patient correlation was not found when patients perceived their problem as psychosocial.

Doctor-patient communication in different European health care systems: relevance and performance from the patients' perspective

Our aim is to investigate differences between European health care systems in the importance attached by patients to different aspects of doctor-patient communication and the GPs' performance of these aspects, both being from the patients' perspective. 3658 patients of 190 GPs in six European countries (Netherlands, Spain, United Kingdom, Belgium, Germany, Switzerland) completed pre- and post-visit questionnaires about relevance and performance of doctor-patient communication. Data were analyzed by variance analysis and by multilevel analysis. In the non-gatekeeping countries, patients considered both biomedical and psychosocial communication aspects to be more important than the patients in the gatekeeping countries. Similarly, in the patients' perception, the non-gatekeeping GPs dealt with these aspects more often. Patient characteristics (gender, age, education, psychosocial problems, bad health, depressive feelings, GPs' assessment of psychosocial background) showed many relationships. Of the GP characteristics, only the GPs' psychosocial diagnosis was associated with patient-reported psychosocial relevance and performance. Talking about biomedical issues was more important for the patients than talking about psychosocial issues, unless the patients presented psychosocial problems to the GP. Discrepancies between relevance and performance were apparent, especially with respect to biomedical aspects. The implications for health policy and for general practitioners are discussed.