End-of-life decision-making in the emergency department and intensive care unit: Health professionals' perspectives on and knowledge of the law in Queensland

OBJECTIVE

To investigate ED and intensive care unit healthcare professionals' perspectives and knowledge of the law that underpins end-of-life decision-making in Queensland, Australia.

METHODS

An online survey with questions about perspectives, perceived, and actual, knowledge of the law was distributed by the professional organisations of medical practitioners, nurses and social workers who work in Queensland EDs and intensive care units.

RESULTS

The survey responses of 126 healthcare professionals were included in the final analysis. Most respondents agreed that the law was relevant to end-of-life decision-making, but that clinician and family consensus mattered more than following the law. Generally, doctors' legal knowledge was higher than nurses'; however, there were significant gaps in the knowledge of all respondents about the operation of advance health directives in Queensland.

CONCLUSIONS

The legal framework that supports end-of-life decision-making for adults who lack decision-making capacity has been in place for more than two decades. Despite frequently being involved in making or enacting these decisions, gaps in the legal knowledge of healthcare professionals who work in EDs and intensive care units in Queensland are evident. Further research to better understand how to improve knowledge and application of the law is warranted.

Family Involvement in the End-of-Life Decision-Making Process: Legal and Bioethical Analysis of Empirical Findings

End-of-life decision making involves clinicians, patients, and relatives; yet, the law in Israel hardly recognises the role of relatives. This raises the question of the law's impact in practice and, hence, whether it should be amended. This issue is examined on the basis of findings from a qualitative, interview-based study conducted in Israel among relatives of dying patients. The findings indicate that there are areas in which clinicians and relatives do not adhere to the law in the end-of-life decision-making process. For example, they do not always ascertain the patient's end-of-life preferences, which ignores a patient's right to autonomy and their right to make informed decisions. The apparent gaps between the actual conduct of clinicians and relatives on the one hand and the directives of the Israeli Dying Patient Act 2005 on the other, lead us to propose several changes to the Act.

Life-Sustaining Treatment States in Korean Cancer Patients after Enforcement of Act on Decisions on Life-Sustaining Treatment for Patients at the End of Life

PURPOSE

In Korea, the "Act on Hospice and Palliative Care and Decisions on Life-sustaining Treatment for Patients at the End of Life" was enacted on February 4, 2018. This study was conducted to analyze the current state of life-sustaining treatment decisions based on National Health Insurance Service (NHIS) data after the law came into force.

MATERIALS AND METHODS

The data of 173,028 cancer deaths were extracted from NHIS qualification data between November 2015 and January 2019.

RESULTS

The number of cancer deaths complied with the law process was 14,438 of 54,635 cases (26.4%). The rate of patient self-determination was 49.0%. The patients complying with the law process have used a hospice center more frequently (28% vs. 14%). However, the rate of intensive care unit (ICU) admission was similar between the patients who complied with and without the law process (ICU admission, 23% vs. 21%). There was no difference in the proportion of patients who had undergone mechanical ventilation and hemodialysis in the comparative analysis before and after the enforcement of the law and the analysis according to the compliance with the law. The patients who complied with the law process received cardiopulmonary resuscitation at a lower rate.

CONCLUSION

The law has positive effects on the rate of life-sustaining treatment decision by patient's determination. However, there was no sufficient effect on the withholding or withdrawing of life-sustaining treatment, which could protect the patient from unnecessary or harmful interventions.

Do advance directive attitudes and perceived susceptibility and end-of-life life-sustaining treatment preferences between patients with heart failure and cancer differ?

There is limited evidence on the relationships of preference for end-of-life life-sustaining treatments [LSTs] and diagnostic contexts like heart failure [HF] or cancer, and patient attitudes toward and perceived susceptibility to use advance directives [ADs]. Thus, this study aimed to compare attitudes and perceived susceptibility between HF patients and community-dwelling patients with cancer, and examine the associations of these variables with their preference for each LST (cardiopulmonary resuscitation [CPR], ventilation support, hemodialysis, and hospice care). Secondary data were obtained from 36 outpatients with HF (mean age, 65.44 years; male, 69.4%) and 107 cancer patients (mean age, 67.39 years; male, 32.7%). More patients with HF preferred CPR than cancer patients (41.7% and 15.9%, χ2 = 8.88, P = 0.003). Attitudes and perceived susceptibility were similar between the two diagnostic cohorts. HF patients and those with more positive attitudes had greater odds of preferring CPR (odds ratio [OR] = 3.02, confidence interval [CI] = 1.19, 7.70) and hospice care (OR = 1.14, CI = 1.06, 1.23), respectively. HF diagnosis and AD attitudes increased the preference for CPR and hospice care, respectively. This suggests that it is important to gain positive attitudes toward ADs and consider diagnostic context to facilitate informed decision-making for LSTs.

Medico-legal and bioethical perspectives following the constitutional legitimacy of assisted suicide in Italy

Assisted suicide is the subject of much debate throughout the world. In Italy, on 24 September 2019, the Italian Constitutional Court legitimised assisted suicide under certain conditions: self-determination capacity, irreversible illness and intense physical/psychological suffering of the patient. This historic judgement surely paved the way for an evolution of the Italian legal framework on the matter but also raised some challenging medico-legal and bioethical questions. This study aims at analysing two of the most controversial among them: the inclusion of psychiatric patients among eligible patients for assisted suicide and the position of physicians related to their right to conscientious objection.

Survival after in-hospital cardiopulmonary resuscitation from 2003 to 2013: An observational study before legislation on the life-sustaining treatment decision-making act of Korean patients

We analyzed cardiopulmonary resuscitation (CPR) rates, deaths preceded by CPR, and survival trends after in-hospital CPR, using a sample of nationwide Korean claims data for the period 2003 to 2013.The Korean National Health Insurance Service-National Sample Cohort is a stratified random sample of 1,025,340 subjects selected from among approximately 46 million Koreans. We evaluated the annual incidence of CPR per 1000 admissions in various age groups, hospital deaths preceded by CPR, and survival rate following in-hospital CPR. Analyses of the relationships between survival and patient and hospital characteristics were performed using logistic regression analysis.A total of 5918 in-hospital CPR cases from 2003 to 2013 were identified among eligible patients. The cumulative incidence of in-hospital CPR was 3.71 events per 1000 admissions (95% confidence interval 3.62-3.80). The CPR rate per 1000 admissions was highest among the oldest age group, and the rate decreased throughout the study period in all groups except the youngest age group. Hospital deaths were preceded by in-hospital CPR in 18.1% of cases, and the rate decreased in the oldest age group. The survival-to-discharge rate in all study subjects was 11.7% during study period, while the 6-month and 1-year survival rates were 8.0% and 7.2%, respectively. Survival tended to increase throughout the study period; however, this was not the case in the oldest age group. Age and malignancy were associated with lower survival rates, whereas myocardial infarction and diabetes mellitus were associated with higher survival rates.Our result shows that hospital deaths were preceded by in-hospital CPR in 18.1% of case, and the survival-to-discharge rate in all study subjects was 11.7% during the study period. Survival tended to increase throughout the study period except for the oldest age group. Our results provide reliable data that can be used to inform judicious decisions on the implementation of CPR, with the ultimate goal of optimizing survival rates and resource utilization.

End-of-life medical decision-making for children in custody: A collaborative, multi-stakeholder practical approach

BACKGROUND

Parents have a constitutionally-protected, fundamental right to make decisions concerning the health and well-being of their children, afforded by the Due Process Clause of the Fourteenth Amendment. However, parental rights are not absolute, and may be curtailed after a finding of parental "unfitness" including perpetration of egregious child abuse/neglect. Court intervention may be necessary to assert "parens patriae" authority to protect a child's well-being. Disagreements over medical care for a child (particularly when parent maltreatment resulted in life-altering clinical conditions and parents are suspected of perpetrating abusive injuries) often pose conflicts of interest. End-of-life decision-making involving abuse perpetrators may be influenced by self-interest, due to potential for escalation of criminal charges.

OBJECTIVE

Discuss medico-legal decision-making for children in child welfare custody using a detailed case example involving a child near-fatally, abusively injured by his parents; review of relevant case law/national legal precedents; and clinical policy statements guiding end-of-life decision-making for pediatric patients.

PARTICIPANTS/SETTING/METHODS

Using an exploratory, quasi-qualitative approach, perceived experiences of purposefully-selected taskforce members identified key themes that informed a care de-escalation protocol, implemented across the state.

RESULTS

Key themes included coordinated communication, expedited legal proceedings, and balancing child's best interest (the right not to suffer for a prolonged period of time or sustain complications) with parents' rights and due process concerns, and informed protocol development.

CONCLUSIONS

Practicable guidance established in the protocol can be theoretically adapted at the local level to address the complexity inherent in end-of-life decision-making for children in custody.

End-of-life decision-making and advance care directives in Italy. A report and moral appraisal of recent legal provisions

The present article reviews the state of public debate and legal provisions concerning end-of-life decision-making in Italy and offers an evaluation of the moral and legal issues involved. The article further examines the content of a recent law concerning informed consent and advance treatment directives, the main court pronouncements that formed the basis for the law, and developments in the public debate and important jurisprudential acts subsequent to its approval. The moral and legal grounds for a positive evaluation of this law, which attests that the patient may withhold or withdraw from life-prolonging treatment, will be offered with reference to liberal approaches and particularly to the frameworks of care and virtue ethics; but reasons will also be offered in order to consider not only the latter but also broader range of end-of-life treatment decisions as morally apt options. In this light, we argue in favour of a further development of the Italian legislation to encompass forms of assisted suicide and active euthanasia.

Dying with Dignity; Living with Laws (and Ethics)

An increasing number of jurisdictions allow individuals to obtain medication prescribed by their physicians for medical assistance in dying (MAID). But discussion of whether (and to what extent) individuals have the right to use the health care system to control the time and manner of their death is not limited to MAID. The right also exists in other contexts, such as directing the withdrawal of life-sustaining treatments. Palliative (or terminal) sedation involves medications to render a patient unconscious, coupled with either the withdrawal of artificial nutrition and hydration or their not being administered at all. In high-enough doses, these medications may further suppress already-weakened cardiopulmonary function even if there is no intent to hasten death. When teaching about these topics, I challenge students to consider whether there are meaningful differences between practices like euthanasia, MAID, aggressive use of morphine, terminal sedation, or the withdrawal of ventilator support. Whether their differences are morally, ethically, or legally meaningful can be difficult to tease out. After recently watching a loved one, whom I call "Stephan," direct the time and manner of his death within hospice care in a state that does not allow MAID, I am less inclined than ever to believe that the differences are meaningful in a way the law should recognize.

Waiting for a miracle or best medical practice? End-of-life medical ethical dilemmas in Bahrain

BACKGROUND AND OBJECTIVES

In Bahrain, maintaining life support at all costs is a cultural value considered to be embedded in the Islamic religion. We explore end-of-life decision making for brain dead patients in an Arab country where medical cultures are dominated by Western ideas and the lay culture is Eastern.

METHODS

In-depth interviews were conducted from February to April 2018 with 12 Western-educated Bahraini doctors whose medical practice often included end-of-life decision making. Discussions were about who should make withdrawal of life support decisions, how decisions are made and the context for decision making. To develop results, we used the inductive method of thematic analysis.

RESULTS

Informants considered it difficult to engage non-medical people in end-of-life decisions because of people's reluctance to talk about death and no legal clarity about medical responsibilities. There was disagreement about doctors' roles with some saying that end-of-life decisions were purely medical or purely religious but most maintaining that such decisions need to be collectively owned by medicine, patients, families, religious advisors and society. Informants practised in a legal vacuum that made their ethics interpretations and clinical decision making idiosyncratic regarding end-of-life care for brain dead patients. Participants referred to contrasts between their current practice and previous work in other countries, recognising the influences of religious and cultural dimensions on their practice in Bahrain.

CONCLUSIONS

End-of-life decisions challenge Western-trained doctors in Bahrain as they grapple with aligning respect for local culture with their training in the ethical practice of Western medicine.

Oral medical assistance in dying (MAiD): informing practice to enhance utilization in Canada

The legislation Bill C-14 legalized medical assistance in dying (MAiD) in Canada. After thorough assessments of eligibility by two clinicians, Bill C-14 allows for both intravenous-assisted death by a clinician (euthanasia) and prescription of oral medication for self-administration (assisted suicide). Nevertheless, since inception in June 2016, intravenous euthanasia is the main form of delivery of assisted death in Canada. The reasons why oral MAiD is underutilized in Canada are multifactorial. Currently, there is no consensus on either the medications or the protocols for oral administration, nor a comprehensive understanding of the potential side effects and complications associated with different regimens. The quality of evidence for optimal MAiD medications is low, so any suggested recommendations can only be informed by the global but generally anecdotal experience. The challenges for implementing oral MAiD in Canada include a need to enhance clinician comfort in prescribing oral medications as an alternative to intravenous administration. The goals for ideal oral MAiD medications are 100% effectiveness and minimal side effects, while ensuring that the needed dose is both palatable and deliverable in a tolerable oral volume. The Netherlands has the most experience worldwide and barbiturates have emerged as the most common, efficacious, and tolerable agents by patients. Based on this global experience and the over-arching goals for oral MAiD, we recommend the use of a secobarbital suspension combined with antiemetic prophylaxis.

An NHS Trust and others v Y and another [2018] UKSC 46: Reducing the Role of the Courts in Treatment Withdrawal

In An NHS Trust and others v Y and another, the Supreme Court was asked to address the question of whether a court order must always be obtained before clinically assisted nutrition and hydration (CANH), which is keeping alive a person with a prolonged disorder of consciousness (PDOC). This case note explores the Court's decision to dispense with the need for such a court order and analyses that important change in approach from the perspective of the right to life protected in Article 2 European Convention on Human Rights (ECHR) as well as in the broader context of end of life decision-making.

Drawing the line on physician-assisted death

Drawing the line on physician assistance in physician-assisted death (PAD) continues to be a contentious issue in many legal jurisdictions across the USA, Canada and Europe. PAD is a medical practice that occurs when physicians either prescribe or administer lethal medication to their patients. As more legal jurisdictions establish PAD for at least some class of patients, the question of the proper scope of this practice has become pressing. This paper presents an argument for restricting PAD to the terminally ill that can be accepted by defenders as well as critics of PAD for the terminally ill. The argument appeals to fairness-based paternalism and the social meaning of medical practice. These two considerations interact in various ways, as the paper explains. The right way to think about the social meaning of medical practice bears on fair paternalism as it relates to PAD and vice versa. The paper contends that these considerations have substantial force when directed against proposals to extend PAD to non-terminally ill patients, but considerably less force when directed against PAD for the terminally ill. The paper pays special attention to the case of non-terminally ill patients who suffer from treatment-resistant depression, as these patients present a potentially strong case for extending PAD beyond the terminally ill.

The perils of medico-legal advocacy in ICU conflicts at the end of life: A qualitative study of what happens when advocacy and best interests collide

An unexplored aspect of conflicts and conflict resolution in the ICU at EOL is the role of advocacy in both medicine and law.

GOAL

Qualitative study to explore perspectives of SDM/patient lawyers on issues of advocacy at EOL to better understand conflicts and resolution processes.

METHODS

Purposive sampling with criterion and snowball techniques were used to recruit 11 experienced lawyers for semi-structured interviews. Interviews explored respondents' beliefs, views, and experiences with conflicts; were audio-recorded, coded inductively and iteratively following interpretive analysis. Recurring themes were identified using NVivo Qualitative Software.

RESULTS

We interviewed 11 participants and achieved conceptual saturation. Participants identified insufficient advocacy and overaggressive advocacy as major contributors to the initiation of ICU conflicts and the inhibition of resolution processes before and after the legal system is engaged. These breakdowns in advocacy contribute to challenges when conflicts arise, leading to prolongation of conflict-resolution processes and to outcomes that sometimes reflect the goals of legal advocacy rather than patient-centred goals.

CONCLUSION

This study explores legal perspective of conflict at EOL and how these perspectives can be used to inform the development of better approaches to conflict resolution.

Responding Better to Desperate Parents: Warnings from the Alfie Evans Saga

The end-of-life litigation involving Alfie Evans (9 May 2016 - 28 April 2018) from Liverpool, England, who suffered from an incurable and degenerative neurological condition was extraordinary. It emerged in the shadow of comparable but not as extensive litigation enabled by crowdfunding in relation to Ashya King and Charlie Gard. Although Alfie's parents lost repeatedly in the High Court, the Court of Appeal and the Supreme Court of England, as well as before the European Court of Human Rights, they persisted in bringing more legal challenges. The public relations campaign on their behalf at times was threatening and accusatory of the clinicians and of Alder Hey Hospital. Both persons employed at the Christian Legal Centre, which represented the parents at times, and medical practitioners from Europe who participated in forensic assessments behaved unethically. There are many lessons to be learned from the Alfie Evans saga. If we are to maintain morale and commitment among those who provide paediatric clinical services to the very ill and the dying, they must be protected from the public relations and litigation campaigns deployed by those purporting to represent the Alfie Evans family, and better non-adversarial methods need to be constructed as a matter of urgency to resolve matters involving disagreements about the treatment of terminally ill children.

Medicare and Advance Planning: The Importance of Context

In January 2016, a long-delayed Medicare change took effect. The Medicare program will now reimburse doctors for time they spend talking with patients about end-of-life care. This is the move that Sarah Palin and other Affordable Care Act critics said would authorize government "death panels" to decide whether older Americans should live or die. Today virtually no one buys into Palin's death panel rhetoric. But many people do think the Medicare change is a big deal. Representative Earl Blumenauer, a Democrat from Oregon who sponsored the original ACA reimbursement proposal, lauded the Medicare provision as "a turning point in end-of-life care." Others are not so sure about that. After all, laws promoting advance care planning have existed for decades. The federal Patient Self-Determination Act of 1990 and the many court decisions and state laws supporting advance care planning have had relatively little impact. Similarly, legal recognition of physician orders for life-sustaining treatment as advance planning instruments have not produced the improvements that were predicted. And from a broad perspective, advance care planning is a small piece of the puzzle. The effort to improve end-of-life care must take into account the limitations of advance decision-making, as well as the overriding importance of the general standard of care for terminally ill patients.

Prevailing Ethical Dilemmas Encountered by Physicians in Terminal Cancer Care Changed After the Enactment of the Natural Death Act: 15 Years' Follow-up Survey

CONTEXT

Advance directive laws have influences on ethical dilemmas encountered by physicians caring for terminal cancer patients.

OBJECTIVES

To identify the prevailing ethical dilemmas among terminal care physicians 15 years after the Natural Death Act was enacted in Taiwan.

METHODS

This study is a cross-sectional survey from April 2014 to February 2015 using the clustering sampling method and a well-structured questionnaire. Targeted participants included physicians at oncology and related wards or palliative care units where terminal cancer care may be provided in Taiwan.

RESULTS

Among the 500 physicians surveyed, 383 responded (response rate 76.6%) and 346 valid questionnaires were included in the final analysis (effective response rate 69.2%). The most frequently identified ethical dilemma was "place of care," followed by "use of antimicrobial agents" and "artificial nutrition and hydration." The dilemma of "truth telling," which ranked first in the 2005-2006 survey, now ranked at the fourth place. Stepwise logistic regression analysis revealed that female gender and knowledge of palliative care were negatively correlated with the extent of dilemmas regarding issues of "life and death."

CONCLUSION

The prevailing ethical dilemmas have changed in Taiwan 15 years after the enactment of the Natural Death Act, supporting that some previous strategies had worked. Our results suggest that education on the core values of palliative care, improvement of community-based hospice care program, and creating treatment guidelines with prognostication may resolve the current dilemmas. This type of survey should be adapted by individual countries to guide policy decisions on end-of-life care.

For End-of-Life Care, Fresh Challenges Begin

The logistics of entering a valid in-hospital DNR order are about to become considerably more complex. A law taking effect in April lays out new requirements affecting physicians in hospitals or health care facilities.

Law as Clinical Evidence: A New ConstitutiveModel of Medical Education and Decision-Making

Over several decades, ethics and law have been applied to medical education and practice in a way that reflects the continuation during the twentieth century of the strong distinction between facts and values. We explain the development of applied ethics and applied medical law and report selected results that reflect this applied model from an empirical project examining doctors' decisions on withdrawing/withholding treatment from patients who lack decision-making capacity. The model is critiqued, and an alternative "constitutive" model is supported on the basis that medicine, medical law, and medical ethics exemplify the inevitable entanglement of facts and values. The model requires that ethics and law be taught across the medical education curriculum and integrated with the basic and clinical sciences and that they be perceived as an integral component of medical evidence and practice. Law, in particular, would rank as equal in normative authority to the relevant clinical scientific "facts" of the case, with graduating doctors having as strong a basic command of each category as the other. The normalization of legal knowledge as part of the clinician's evidence base to be utilized in practice may provide adequate consolation for clinicians who may initially resent further perceived incursions on their traditional independence and discretion.

The 'French exception': the right to continuous deep sedation at the end of life

In 2016, a law came into force in France granting terminally ill patients the right to continuous deep sedation (CDS) until death. This right was proposed as an alternative to euthanasia and presented as the 'French response' to problems at the end of life. The law draws a distinction between CDS and euthanasia and other forms of sympton control at the end of life. France is the first country in the world to legislate on CDS . This short report describes the particular context and underlying social values that led to this piece of legislation, and explores its meaning in the wider French context.

Legal Support for Palliative Care Patients

CONTEXT

Palliative care patients face legal issues that impact their quality of life. Legal support, embedded in holistic palliative care services, has developed globally over the last decade to address this.

OBJECTIVES

This article aims to trace the origins of legal support for palliative care patients, detail models of legal support, and describe achievements and challenges.

METHODS

The article draws on years of work in this area and the available literature.

RESULTS

Common legal issues include disposing of property and drafting wills, planning for children, dealing with debt and securing social benefits, and addressing discrimination. Diverse approaches to integrating legal support include developing paralegal skills, accessing skilled legal advice, empowering patients and families, and building awareness of rights among health care workers.

CONCLUSION

There is robust and growing acceptance of legal support as a key component of holistic palliative care, and many palliative care professionals are identifying and addressing the legal needs they encounter through mediation, guidance on basic rights, or referrals to a lawyer. Addressing legal problems can contribute to peace of mind, well-being, and the health of patients.

Existential decision-making in a fatal progressive disease: how much do legal and medical frameworks matter?

BACKGROUND

Healthcare legislation in European countries is similar in many respects. Most importantly, the framework of informed consent determines that physicians have the duty to provide detailed information about available therapeutic options and that patients have the right to refuse measures that contradict their personal values. However, when it comes to end-of-life decision-making a number of differences exist in the more specific regulations of individual countries. These differences and how they might nevertheless impact patient's choices will be addressed in the current debate.

MAIN TEXT

In this article we show how the legal and medical frameworks of Germany, Poland and Sweden differ with regard to end-of-life decisions for patients with a fatal progressive disease. Taking Amyotrophic Lateral Sclerosis (ALS) as an example, we systematically compare clinical guidelines and healthcare law, pointing out the country-specific differences most relevant for existential decision-making. A fictional case report discusses the implications of these differences for a patient with ALS living in either of the three countries. Patients with ALS in Germany, Poland and Sweden are confronted with a similar spectrum of treatment options. However, the analysis of the normative frameworks shows that the conditions for making existential decisions differ considerably in Germany, Poland and Sweden. Specifically, these differences concern (1) the legal status of advance directives, (2) the conditions under which life-sustaining therapies are started or withheld, and (3) the legal regulations on assisted dying.

CONCLUSION

According to the presented data, regulations of terminating life-sustaining treatments and the framework of "informed consent" are quite differently understood and implemented in the legal setting of the three countries. It is possible, and even likely, that these differences in the legal and medical frameworks have a considerable influence on existential decisions of patients with ALS.

Morally-Relevant Similarities and Differences Between Assisted Dying Practices in Paradigm and Non-Paradigm Circumstances: Could They Inform Regulatory Decisions?

There has been contentious debate over the years about whether there are morally relevant similarities and differences between the three practices of continuous deep sedation until death, physician-assisted suicide, and voluntary euthanasia. Surprisingly little academic attention has been paid to a comparison of the uses of these practices in the two types of circumstances in which they are typically performed. A comparative domains of ethics analysis methodological approach is used in the paper to compare 1) the use of the three practices in paradigm circumstances, and 2) the use of the practices in paradigm circumstances to their use in non-paradigm circumstances. The analytical outcomes suggest that a bright moral line cannot be demonstrated between any two of the practices in paradigm circumstances, and that there are significant, morally-relevant distinctions between their use in paradigm and non-paradigm circumstances. A thought experiment is employed to illustrate how these outcomes could possibly inform the decisions of hypothetical deliberators who are engaged in the collaborative development of assisted dying regulatory frameworks.

[Principles and challenges of law n° 2016-87 of 2 February 2016 creating new rights for the sick and the end-of-life]

Principles and challenges of law n° 2016-87 of 2 february 2016 creating new rights for the sick and the end-of-life. This law reinforces and modifies the rights of patient. Advance directives become binding but are not unenforceable. There are two types of directives depending on whether the person is or is not suffering from a serious illness at the time of writing. Medical doctor has to respect them except three situations: a vital emergency, an unappropriated character or a redaction which is not conform to the patient's medical situation. Advance directives have no limited duration. They can be written in concordance with a model elaborated by the French high health authority. They should be included in the shared medical record. Medical doctors are encouraged to help the patient in the writing of his advance directives. The law introduces the right to a deep and continuous sedation maintained until the death in 3 specific situations: at the patient's request when his vital prognostic is engaged in a brief term, and when he presents a suffering refractory to treatments; at the patient's request when he chooses to withdraw a treatment which maintain him artificially in life, this withdrawing would lead to his vital prognostic in a short time and susceptible to involve an unbearable suffering; when the patient is unable to express his wishes and when the practitioner, after a collegiate procedure, withdraws a treatment which maintains the patient in life, resulting refusal an unreasonable obstinacy.

Aid-in-dying laws and the physician's duty to inform

On 19 July 2016, three medical organisations filed a federal lawsuit against representatives from several Vermont agencies over the Patient Choice and Control at End of Life Act. The law is similar to aid-in-dying (AID) laws in four other US states, but the lawsuit hinges on a distinctive aspect of Vermont's law pertaining to patients' rights to information. The lawsuit raises questions about whether, and under what circumstances, there is an ethical obligation to inform terminally ill patients about AID as an end-of-life option. Much of the literature on clinical communication about AID addresses how physicians should respond to patient requests for assisted dying, but neglects the question of how physicians should approach patients who may not know enough about AID to request it. In this article, I examine the possibility of an affirmative duty to inform terminally ill patients about AID in light of ethical concerns about professional responsibilities to patients and the maintenance of the patient-provider relationship. I suggest that we should not take for granted that communication about AID ought to be patient-initiated, and that there may be circumstances in which physicians have good reasons to introduce the topic themselves. By identifying ethical considerations that ought to inform such discussions, I aim to set an agenda for future bioethical research that adopts a broader perspective on clinical communication about AID.

Euthanasia embedded in palliative care. Responses to essentialistic criticisms of the Belgian model of integral end-of-life care

The Belgian model of 'integral' end-of-life care consists of universal access to palliative care (PC) and legally regulated euthanasia. As a first worldwide, the Flemish PC organisation has embedded euthanasia in its practice. However, some critics have declared the Belgian-model concepts of 'integral PC' and 'palliative futility' to fundamentally contradict the essence of PC. This article analyses the various essentialistic arguments for the incompatibility of euthanasia and PC. The empirical evidence from the euthanasia-permissive Benelux countries shows that since legalisation, carefulness (of decision making) at the end of life has improved and there have been no significant adverse 'slippery slope' effects. It is problematic that some critics disregard the empirical evidence as epistemologically irrelevant in a normative ethical debate. Next, rejecting euthanasia because its prevention was a founding principle of PC ignores historical developments. Further, critics' ethical positions depart from the PC tenet of patient centeredness by prioritising caregivers' values over patients' values. Also, many critics' canonical adherence to the WHO definition of PC, which has intention as the ethical criterion is objectionable. A rejection of the Belgian model on doctrinal grounds also has nefarious practical consequences such as the marginalisation of PC in euthanasia-permissive countries, the continuation of clandestine practices and problematic palliative sedation until death. In conclusion, major flaws of essentialistic arguments against the Belgian model include the disregard of empirical evidence, appeals to canonical and questionable definitions, prioritisation of caregiver perspectives over those of patients and rejection of a plurality of respectable views on decision making at the end of life.

The role of law in decisions to withhold and withdraw life-sustaining treatment from adults who lack capacity: a cross-sectional study

OBJECTIVES

To determine the role played by law in medical specialists' decision-making about withholding and withdrawing life-sustaining treatment from adults who lack capacity, and the extent to which legal knowledge affects whether law is followed.

DESIGN

Cross-sectional postal survey of medical specialists.

SETTING

The two largest Australian states by population.

PARTICIPANTS

649 medical specialists from seven specialties most likely to be involved in end-of-life decision-making in the acute setting.

MAIN OUTCOME MEASURES

Compliance with law and the impact of legal knowledge on compliance.

RESULTS

649 medical specialists (of 2104 potential participants) completed the survey (response rate 31%). Responses to a hypothetical scenario found a potential low rate of legal compliance, 32% (95% CI 28% to 36%). Knowledge of the law and legal compliance were associated: within compliers, 86% (95% CI 83% to 91%) had specific knowledge of the relevant aspect of the law, compared with 60% (95% CI 55% to 65%) within non-compliers. However, the reasons medical specialists gave for making decisions did not vary according to legal knowledge.

CONCLUSIONS

Medical specialists prioritise patient-related clinical factors over law when confronted with a scenario where legal compliance is inconsistent with what they believe is clinically indicated. Although legally knowledgeable specialists were more likely to comply with the law, compliance in the scenario was not motivated by an intention to follow law. Ethical considerations (which are different from, but often align with, law) are suggested as a more important influence in clinical decision-making. More education and training of doctors is needed to demonstrate the role, relevance and utility of law in end-of-life care.

[Therapeutic Decisions Concerning Severe Neurological Diseases and at the End of Life]

Modern medicine increasingly enables survival of life-threatening diseases. On the other side, however, especially in Neurology, the questions have to be addressed how intensive the initial treatment should be and how to deal with residual states when severe functional or cognitive deficits are expected. In these cases, it is not only important to decide which medical measures are appropriate for the patient, but also whether, given the prognosis, the patient would agree with the suggested measures. This article first describes the basis for each medical action, i. e. ethical aspects, medical indication and patient's agreement. Then the different ways to find out the patient's wishes depending on his ability to agree as well as the possibilities for advance directives (including Advance Care Planning) and health care proxies are discussed. Finally, suggestions for adequate documentation are given. In parallel, the relevant legal paragraphs and statements of the German medical association are presented.

[Guide document for assistance the end of the life]

There are not any laws in Italy that rule the path of the end of life. Therefore, the doctor has to take as a reference the Supreme Judgment of the Court of Cassation 16/10/2007 n 21748. The author is proposing a different, realistic and convenient form that could be used by the patient and both his tutor and doctor to walk through the path that brings to the end of life. This document shows respect for the sanctity of life and safeguards willingness and dignity of the patient. Its purpose is to register the treatment for symptoms that leads to death, basing the relationship between a patient and his doctor on trust and confidence.

[Anticipating the end of life, planning for the loss of intellectual autonomy]

More than ten years after the Leonetti law was passed, the French parliament has definitively adopted legislation granting new rights to people at the end of life. This new legislation is the result of persistent public pressure. French people want to see their wishes respected with regard to their end-of-life care. How and in what conditions should such measures be applied in the case of patients at the end of life and with diminished intellectual autonomy?

Caring for the dying in a developing country, how prepared are we?

End of life care is framework to allow for a peaceful, comfortable and dignified death while considering the patients' personal and religious values, bioethics and knowledge of the disease process. A well planned end of life pathway should allow for the flexibility to shift from an active (or aggressive) treatment approach to one of comfort and care when initial interventions have failed. The need for this pathway is most apparent in the intensive care setting. Implementation of a pathway will face various challenges due to religious and cultural beliefs, education of healthcare providers to carry out difficult discussions and larger socioeconomic implications. Clear medico-legal framework will be required to support this pathway. In conclusion, an end of life pathway tailored to our local needs is the way forward in allowing for dignified death of terminally ill patients; this will require the active participation of medical societies, religious leaders, healthcare providers, patients and their care givers.

Medical murder in Belgium and the Netherlands

This article is a response to Raphael Cohen-Almagor's paper entitled 'First do no harm: intentionally shortening lives of patients without their explicit request in Belgium'. His paper deals with very important matters of life and death, however its concept usage is in part misleading. For instance, the fact that medical murder takes place both in Belgium and the Netherlands is missed. Cohen-Almagor calls such acts 'worrying' and considers them to be 'abuse'. However, it remains an open question whether or not there can be such a thing as legitimate murder in a medical context. From the combined perspectives of justice and the duty to end unbearable suffering, there might be. Thus, key arguments for euthanasia are also prominent in an argument for medical murder.