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Rahimian Z, Rahimian L, Lopez‐Castroman J, Ostovarfar J, Fallahi MJ, Nayeri MA, Vardanjani HM. What medical conditions lead to a request for euthanasia? A rapid scoping review. Health Sci Rep 2024; 7:e1978. [PMID: 38515545 PMCID: PMC10955044 DOI: 10.1002/hsr2.1978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 02/07/2024] [Accepted: 02/28/2024] [Indexed: 03/23/2024] Open
Abstract
Background and Aims Euthanasia is a controversial issue related to the right to die. Although euthanasia is mostly requested by terminally sick individuals, even in societies where it is legal, it is unclear what medical conditions lead to euthanasia requests. In this scoping review, we aimed to compile medical conditions for which euthanasia has been requested or performed around the world. Methods The review was preferred reporting items for systematic reviews and meta-analysis for scoping reviews (PRISMA-ScR) checklist. Retrieved search results were screened and unrelated documents were excluded. Data on reasons for conducting or requesting euthanasia along with the study type, setting, and publication year were extracted from documents. Human development index and euthanasia legality were also extracted. Major medical fields were used to categorize reported reasons. Group discussions were conducted if needed for this categorization. An electronic search was undertaken in MEDLINE through PubMed for published documents covering the years January 2000 to September 2022. Results Out of 3323 records, a total of 197 papers were included. The most common medical conditions in euthanasia requests are cancer in a terminal phase (45.4%), Alzheimer's disease and dementia (19.8%), constant unbearable physical or mental suffering (19.8%), treatment-resistant mood disorders (12.2%), and advanced cardiovascular disorders (12.2%). Conclusion Reasons for euthanasia are mostly linked to chronic or terminal physical conditions. Psychiatric disorders also lead to a substantial proportion of euthanasia requests. This review can help to identify the features shared by conditions that lead to performing or requesting euthanasia.
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Affiliation(s)
- Zahra Rahimian
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
- MD‐MPH Department, School of MedicineShiraz University of Medical SciencesShirazIran
| | - Leila Rahimian
- School of DentistryShiraz University of Medical SciencesShirazIran
| | - Jorge Lopez‐Castroman
- Department of Psychiatry, CHU Nîmes & IGFCNRS‐INSERMUniversity of MontpellierMontpellierFrance
- CIBERSAMMadridSpain
| | - Jeyran Ostovarfar
- MD‐MPH Department, School of MedicineShiraz University of Medical SciencesShirazIran
| | - Mohammad J. Fallahi
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical SciencesShirazIran
| | - Mohammad A. Nayeri
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
- MD‐MPH Department, School of MedicineShiraz University of Medical SciencesShirazIran
| | - Hossein M. Vardanjani
- MD‐MPH Department, School of Medicine, Research Center for Traditional Medicine and History of MedicineShiraz University of Medical SciencesShirazIran
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2
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Şener Ş, Dikmen Y. Attitudes and Behaviors of Palliative Care Nurses on Euthanasia. FLORENCE NIGHTINGALE JOURNAL OF NURSING 2023; 31:S66-S70. [PMID: 37162057 PMCID: PMC10919223 DOI: 10.5152/fnjn.2023.23056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/19/2023] [Indexed: 05/11/2023]
Abstract
This review was planned to present an overview of the findings in the scientific literature on euthanasia, palliative care, and nurses' attitudes and behaviors. A literature search was done in "EBSCO," "PubMed" databases, and "Google Scholar" search engines. In the study, a search was made between January and March 2023 using the keywords "palliative care," "euthanasia," and "nurse attitudes." Articles published in English and accessible were included in the research. Palliative care practices differ according to the health system, socioeconomic status, cultural conditions, geographical location, and education levels of countries On the other hand, discussions on the integration of euthanasia into palliative care practices continue. While palliative care practices differentiate in countries where euthanasia has been legalized, scientific, legal, religious, and ethical discussions continue in countries where euthanasia is not legal. There are many different variables, such as age, gender, professional experience, and cultural and religious factors, that affect nurses' attitudes and behaviors on this issue. It can be suggested that the results of the research, which will evaluate the factors affecting the attitudes of nurses toward euthanasia, death and terminally ill patients, include social changes in order to provide a literature and database in this field.
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Affiliation(s)
- Şenay Şener
- Safranbolu State Hospital, Infection Control Nurse, Karabük, Turkey
| | - Yurdanur Dikmen
- Department of Nursing, Sakarya University of Applied Sciences, Faculty of Health Sciences, Sakarya, Turkey
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3
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Kőmüves S. Palliative Care and Physician Assisted Death. ETHICS IN PROGRESS 2022. [DOI: 10.14746/eip.2022.2.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
In the recent decade quite a few countries and regions legalised physician assisted death. While palliative care is already or becoming the standard end of life care in many countries, the increased availability of physician assisted death coupled with the secularisation of hospice in more settings require – where this has not happened yet – a clear response of palliative care specialists to patients’ requests for physician assisted death. The paper analyses the World Health Organisation’s current description of palliative care with a special focus on its prohibition of hastening death. Some palliative care professionals do not agree with the ban on hastening death, and these professionals’ non-conventional interpretation of palliative care actually seems to meet the wishes of some patients.
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4
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Auret K, Pikora TJ, Gersbach K, Donovan RJ. “Respecting our patients’ choices”: making the organizational decision to participate in voluntary assisted dying provision: findings from semi-structured interviews with a rural community hospice board of management. Palliat Care 2022; 21:161. [PMID: 36114542 PMCID: PMC9482306 DOI: 10.1186/s12904-022-01051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
There is limited literature around how palliative care organizations determine the degree to which they will interface with voluntary assisted dying in jurisdictions where it is legal. The aim of this research was to describe the experience of the board of management of an Australian community-based hospice during their decision-making process around whether to support voluntary assisted dying in the facility, prior to the legislation coming into operation.
Methods
The Board considered this decision over ten meetings in 2020, during which time they received information on the legislation, relevant literature, feedback from workshops which included the community, comment from hospice founders, staff survey results and presentations by clinicians able to discuss the impact of voluntary assisted dying on palliative care services. Members were encouraged to make notes of their own experiences during this time. Following this, semi-structured interviews were conducted with seven of the nine board members. Interviews were audio-recorded and transcribed verbatim and analysed using conventional qualitative content analysis method.
Results
The board members experienced a sense of journey in reaching an overall decision, which was to allow full participation in voluntary assisted dying provision for inpatients. Themes based on the journey motif included: starting from a personal view; moving to a hospice perspective; exploring if voluntary assisted dying can be part of end-of-life care; awareness and assessment of risks to the Hospice; arriving at a common platform to vote on; factors facilitating a safe decision-making journey; and personal impact of the journey.
Conclusions
The group highlighted several facilitators of a successful outcome including having adequate time, the availability of useful resources, sound board processes and a trusting culture. The study may provide support to other healthcare organisations as they face similar decisions triggered by legislative change.
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5
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Turillazzi E, Maiese A, Frati P, Scopetti M, Di Paolo M. Physician-Patient Relationship, Assisted Suicide and the Italian Constitutional Court. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:671-681. [PMID: 34674155 DOI: 10.1007/s11673-021-10136-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/06/2021] [Indexed: 06/13/2023]
Abstract
In 2017, Italy passed a law that provides for a systematic discipline on informed consent, advance directives, and advance care planning. It ranges from decisions contextual to clinical necessity through the tool of consent/refusal to decisions anticipating future events through the tools of shared care planning and advance directives. Nothing is said in the law regarding the issue of physician assisted suicide. Following the DJ Fabo case, the Italian Constitutional Court declared the constitutional illegitimacy of article 580 of the criminal code in the part in which it does not exclude the punishment of those who facilitate the suicide when the decision has been freely and autonomously made by a person kept alive by life-support treatments and suffering from an irreversible pathology, the source of physical or psychological suffering that he/she considers intolerable, but fully capable of making free and conscious decisions. Such conditions and methods of execution must be verified by a public structure of the national health service, after consulting the territorially competent ethics committee. This statement admits, within strict and regulated bounds, physician assisted suicide, so widening the range of end-of-life decisions for Italian patients. Future application and critical topics will be called into question by the Italian legislator.
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Affiliation(s)
- E Turillazzi
- Section of Legal Medicine, Department of Clinical, Medical, Molecular Pathology and Critical Medicine, University of Pisa, Via Paolo Savi 57, 56126, Pisa, Italy.
| | - A Maiese
- Section of Legal Medicine, Department of Clinical, Medical, Molecular Pathology and Critical Medicine, University of Pisa, Via Paolo Savi 57, 56126, Pisa, Italy
| | - P Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - M Scopetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - M Di Paolo
- Section of Legal Medicine, Department of Clinical, Medical, Molecular Pathology and Critical Medicine, University of Pisa, Via Paolo Savi 57, 56126, Pisa, Italy
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Maréchal N, Six S, Clemmen E, Baillon C, Tack A, Bauwens S, Noppen M, Distelmans W, Beyer I, Bilsen J. Reporting of Palliative Sedation and Use of Opioids at the End of Life in a Belgian University Hospital: A Pilot Study. J Palliat Med 2021; 25:742-748. [PMID: 34756109 DOI: 10.1089/jpm.2021.0113] [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] [Indexed: 11/13/2022] Open
Abstract
Background: Palliative sedation requires no formal registration in Belgium. For euthanasia, however, there are clear guidelines in certain countries, including mandatory registration and evaluation of cases. Official guidelines have been developed for palliative sedation, but research still shows unskilled use of sedation and unclear demarcation between palliative sedation and euthanasia. Registration could be used to avoid unskilled use of sedation and to avoid use or abuse of sedation to hasten the patient's death (described as "slow/passive euthanasia"). Objective: To evaluate the current practice of palliative sedation and use of opioids and sedatives at the end of life by using a registration document. Design: Retrospective observational study. Setting/Subjects: We included all in-hospital deaths at an academic hospital in Belgium of patients (age ≥18 years) who had received parenteral opioids, benzodiazepines, barbiturates, or other anesthetics during the last 24 hours. Measurements: We investigated indications for palliative sedation, patients' and physicians' characteristics, types of medication used, and the decision-making process with the patients and family. The questionnaires were collected between July 9 and November 25, 2016. The study was approved by the Biomedical Ethics Committee of UZ Brussel (B.U.N. 1432016293). Results: In a population of 124 patients, refractory symptoms were reported in 94.4%. All patients received parenteral opioids (intravenously). Benzodiazepines were used in 51.6%. In 75.8%, physicians reported no change in treatment plan during end of life. Hastening death by increasing analgesics and/or sedatives was mentioned in 19.3%. The treatment plan was discussed with patients in 26.6% of cases. In 6 cases, an explicit intention to hasten death was mentioned; in 36 cases, doses of opioids/sedatives may not have been strictly proportional to symptoms. Conclusion: This Belgian study shows that objective reporting of palliative sedation can be used as a tool to ensure good clinical practice where patients receive the most appropriate end-of-life care, avoiding abusive and injudicious or unskilled use of sedation.
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Affiliation(s)
- Nicolas Maréchal
- Geriatric Department, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Stefaan Six
- Department of Public Health, Mental Health, and Wellbeing Research Group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Eveline Clemmen
- Department of Supportive and Palliative Care, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Catherine Baillon
- Department of Supportive and Palliative Care, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Annelien Tack
- Department of Supportive and Palliative Care, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Sabien Bauwens
- Department of Supportive and Palliative Care, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Marc Noppen
- Vrije Universiteit Brussel (VUB), Board of Directors, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Willem Distelmans
- Department of Supportive and Palliative Care, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Ingo Beyer
- Geriatric Department, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Johan Bilsen
- Department of Public Health, Mental Health, and Wellbeing Research Group, Vrije Universiteit Brussel, Brussels, Belgium
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7
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Ocak S, Tournoy K, Berghmans T, Demedts I, Durieux R, Janssens A, Moretti L, Nackaerts K, Pieters T, Surmont V, Van Eycken L, Vrijens F, Weynand B, van Meerbeeck JP. Lung Cancer in Belgium. J Thorac Oncol 2021; 16:1610-1621. [PMID: 34561034 DOI: 10.1016/j.jtho.2021.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/20/2021] [Accepted: 07/24/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Sebahat Ocak
- Division of Pneumology, CHU UCL Namur (Godinne Site), Université catholique de Louvain (UCLouvain), Yvoir, Belgium; Pole of Pneumology, ENT, and Dermatology (PNEU), Institut de Recherche Expérimentale et Clinique (IREC), UCLouvain, Brussels, Belgium.
| | - Kurt Tournoy
- Division of Pneumology, Onze-Lieve-Vrouw Ziekenhuis (OLV) Aalst and Faculty of Medicine and Life Sciences, Ghent University, Ghent, Belgium
| | - Thierry Berghmans
- Thoracic Oncology Clinic, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Ingel Demedts
- Division of Pneumology, AZ Delta Roeselare, Roeselare, Belgium
| | - Rodolphe Durieux
- Division of Cardiovascular and Thoracic Surgery, CHU Liège, Liège, Belgium
| | | | - Luigi Moretti
- Department of Radiation Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Kristiaan Nackaerts
- Division of Respiratory Oncology/Pneumology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Thierry Pieters
- Cliniques Universitaires St-Luc, UCLouvain, Brussels, Belgium; Pole of Pneumology, ENT, and Dermatology (PNEU), Institut de Recherche Expérimentale et Clinique (IREC), UCLouvain, Brussels, Belgium
| | | | | | - France Vrijens
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium
| | - Birgit Weynand
- Department of Pathology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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8
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Gerson SM, Koksvik GH, Richards N, Materstvedt LJ, Clark D. The Relationship of Palliative Care With Assisted Dying Where Assisted Dying is Lawful: A Systematic Scoping Review of the Literature. J Pain Symptom Manage 2020; 59:1287-1303.e1. [PMID: 31881289 PMCID: PMC8311295 DOI: 10.1016/j.jpainsymman.2019.12.361] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 11/28/2019] [Accepted: 12/13/2019] [Indexed: 01/21/2023]
Abstract
CONTEXT A central approach of palliative care has been to provide holistic care for people who are dying, terminally ill, or facing life-limiting illnesses while neither hastening nor postponing death. Assisted dying laws allow eligible individuals to receive medically administered or self-administered medication from a health provider to end their life. The implementation of these laws in a growing number of jurisdictions therefore poses certain challenges for palliative care. OBJECTIVES To analyze the research literature about the relationship of assisted dying with palliative care, in countries where it is lawful. METHODS A five-stage scoping review process was adapted from the Joanna Briggs Institute. Data sources searched through October 2018 were MEDLINE, CINAHL, PsychINFO, SCOPUS, and ProQuest dissertations and theses, with additional material identified through hand searching. Research studies of any design were included, but editorials or opinion articles were excluded. RESULTS After reviewing 5778 references from searches, 105 were subject to full-text review. About 16 studies were included: from Belgium (n = 4), Canada (n = 1), Switzerland (n = 2), and the U.S. (n = 9). We found that the relationship between assisted dying and palliative care practices in these locations took varied and sometimes combined forms: supportive, neutral, coexisting, not mutually exclusive, integrated, synergistic, cooperative, collaborative, opposed, ambivalent, and conflicted. CONCLUSION The studies in this review cast only partial light on challenges faced by palliative care when assisted dying is legal. There is pressing need for more research on the involvement of palliative care in the developing practices of assisted dying, across a growing number of jurisdictions.
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Affiliation(s)
- Sheri Mila Gerson
- School of Interdisciplinary Studies, Dumfries Campus, University of Glasgow, Scotland, United Kingdom.
| | - Gitte H Koksvik
- School of Interdisciplinary Studies, Dumfries Campus, University of Glasgow, Scotland, United Kingdom
| | - Naomi Richards
- School of Interdisciplinary Studies, Dumfries Campus, University of Glasgow, Scotland, United Kingdom
| | - Lars Johan Materstvedt
- School of Interdisciplinary Studies, Dumfries Campus, University of Glasgow, Scotland, United Kingdom; Faculty of Humanities, Department of Philosophy and Religious Studies, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - David Clark
- School of Interdisciplinary Studies, Dumfries Campus, University of Glasgow, Scotland, United Kingdom
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9
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Salas SP, Salinas RA, Besio M, Micolich C, Arriagada A, Misseroni Raddatz A, Valenzuela CY, Novoa F, BÓrquez EstefÓ G. [Ethical arguments for and against the participation of the medical profession in assisted death: analysis of the Ethics Department of the Chilean Medical Association]. Rev Med Chil 2020; 148:542-547. [PMID: 32730464 DOI: 10.4067/s0034-98872020000400542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 02/03/2020] [Indexed: 11/17/2022]
Affiliation(s)
- SofÍa P Salas
- Departamento de Ética, Colegio Médico de Chile A.G, Santiago, Chile
| | | | - Mauricio Besio
- Departamento de Ética, Colegio Médico de Chile A.G, Santiago, Chile
| | | | | | | | | | - Fernando Novoa
- Departamento de Ética, Colegio Médico de Chile A.G, Santiago, Chile
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Dierickx S, Onwuteaka-Philipsen B, Penders Y, Cohen J, van der Heide A, Puhan MA, Ziegler S, Bosshard G, Deliens L, Chambaere K. Commonalities and differences in legal euthanasia and physician-assisted suicide in three countries: a population-level comparison. Int J Public Health 2019; 65:65-73. [DOI: 10.1007/s00038-019-01281-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/12/2019] [Accepted: 06/28/2019] [Indexed: 01/22/2023] Open
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Miccinesi G, Caraceni A, Garetto F, Zaninetta G, Bertè R, Broglia CM, Farci B, Aprile PL, Luzzani M, Marzi AM, Mercadante S, Montanari L, Moroni M, Piazza E, Pittureri C, Tassinari D, Trentin L, Turriziani A, Zagonel V, Maltoni M. The Path of Cicely Saunders: The “Peculiar Beauty” of Palliative Care. J Palliat Care 2019; 35:3-7. [DOI: 10.1177/0825859719833659] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This paper is aimed at focusing on the writings and the experience of the Hospice movement Founder, Dame Cicely Saunders. The in-depth analysis carried out had the objective of verifying if “the way” of Cicely to understand, live and propose palliative care was still current and “beautiful”, so that we can nowadays refer to her fascinating “Original Palliative Care”. With “beauty” we mean, on the one hand, a way able to allow a personal path of research of the meaning of the disease and of the care, both for those who care and for those who are cared for. On the other hand, it seems to us that Cicely strongly suggests how this path can not be carried out alone, but is only possible within the context of a network of relationships and support, in a so called “relational autonomy”, for the patient, included in a “care ethics”. The authors believe that the work extensively documents as the overall approach of Cicely, traditional but always to be rediscovered, is still today the most convincing way of conception and action of palliative care.
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Affiliation(s)
- Guido Miccinesi
- Clinical Epidemiology Unit, Istituto per lo Studio, la Prevenzione e la Rete Oncologica, Firenze, Italy
| | - Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation Unit, National Tumor Institute (INT) IRCCS Foundation, Milano, Italy
| | - Ferdinando Garetto
- FARO ONLUS Foundation & Palliative Care Unit, Humanitas Gradenigo Hospital, Torino, Italy
| | | | - Raffaella Bertè
- Oncology Department, Palliative Care, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Chiara M. Broglia
- Oncology Unit, Policlinico San Matteo IRCCS Foundation, Pavia, Italy
| | | | - P. Lora Aprile
- Italian College of General Practitioners and Primary Care, Desenzano del Garda, Italy
| | - Massimo Luzzani
- Palliative Care, Department of Geriatrics, Orthogeriatrics and Rehabilitation Frailty Area, E.O. Galliera Hospital, Genova, Italy
| | - Annamaria M. Marzi
- Modena and Reggio Emilia University & Casa Madonna dell’Uliveto Hospice, Albinea, Italy
| | - Sebastiano Mercadante
- Anesthesia & Intensive Care and Pain Relief & Palliative Care Unit, La Maddalena Cancer Center & Palermo University, Palermo, Italy
| | - Luigi Montanari
- Palliative Care Unit, AUSL Romagna (Local Health Authority), Lugo, Italy
| | - Matteo Moroni
- Maria Teresa Chiantore Seragnoli Hospice ONLUS Foundation, Bentivoglio, Italy
| | - Elena Piazza
- Medical Oncology, Luigi Sacco University Hospital, Milano, Italy
| | - Cristina Pittureri
- Palliative Care and Hospice Unit, AUSL Romagna (Local Health Authority), Savignano sul Rubicone, Italy
| | - Davide Tassinari
- Department of Oncology & Hospice and Palliative Care Unit, Degli Infermi Hospital, Rimini, Italy
| | - Leonardo Trentin
- Palliative Care and Pain Therapy Unit, Veneto Institute of Oncology (IOV) IRCCS, Padova, Italy
| | | | - Vittorina Zagonel
- Medical Oncology Unit 1, Veneto Institute of Oncology (IOV) IRCCS, Padova, Italy
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
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12
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Bélanger E, Towers A, Wright DK, Chen Y, Tradounsky G, Macdonald ME. Of dilemmas and tensions: a qualitative study of palliative care physicians' positions regarding voluntary active euthanasia in Quebec, Canada. JOURNAL OF MEDICAL ETHICS 2019; 45:48-53. [PMID: 30377217 DOI: 10.1136/medethics-2017-104339] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/22/2018] [Accepted: 10/08/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES In 2015, the Province of Quebec, Canada passed a law that allowed voluntary active euthanasia (VAE). Palliative care stakeholders in Canada have been largely opposed to euthanasia, yet there is little research about their views. The research question guiding this study was the following: How do palliative care physicians in Quebec position themselves regarding the practice of VAE in the context of the new provincial legislation? METHODS We used interpretive description, an inductive methodology to answer research questions about clinical practice. A total of 18 palliative care physicians participated in semistructured interviews at two university-affiliated hospitals in Quebec. RESULTS Participants positioned themselves in opposition to euthanasia. Their justifications were framed within their professional commitment to not hasten death, which sat in tension with the value of patients' autonomy to choose how to die. Participants described VAE as unacceptable if it impeded opportunities to evaluate and alleviate suffering. Further, they contested government rhetoric that positioned VAE as a way to improve end-of-life care. Participants felt that VAE would diminish the potential of palliative care to relieve suffering. Dilemmas were apparent in their narratives, about reconciling respect for patient autonomy with broader palliative care values, and the value of accompanying and not abandoning patients who make requests for VAE while being committed to neither prolonging nor hastening death. CONCLUSIONS This study provides insight into nuanced positions of experienced palliative care physicians in Quebec and confirms expected tensions between an important stakeholder and the practice of VAE as guided by the new legislation.
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Affiliation(s)
- Emmanuelle Bélanger
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Anna Towers
- Department of Oncology, McGill University, Montreal, Quebec, Canada
| | | | - Yuexi Chen
- Palliative Care McGill, McGill University Montreal, Montreal, Quebec, Canada
| | - Golda Tradounsky
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
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13
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Friedel M, Terwangne BD, Brichard B, Ruysseveldt I, Renard M. The Belgian euthanasia law and its impact on the practises of Belgian paediatric palliative care teams. Int J Palliat Nurs 2018; 24:333-337. [PMID: 30044700 DOI: 10.12968/ijpn.2018.24.7.333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Marie Friedel
- PhD student and research assistant, REsearch Institute for Health and Society, Université Catholique de Louvain; Lecturer, Institut Parnasse-ISEI, Haute Ecole Léonard de Vinci, Brussels, Belgium
| | - Brigitte de Terwangne
- Paediatric Liason Nurse, Interface Pédiatrique, Cliniques Universitaires St Luc, Brussels, Belgium
| | - Bénédicte Brichard
- Oncopediatrician and Head of Department, Department of Pediatric Hemato-oncology, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Marleen Renard
- Oncopediatrician, Department of Paediatric Hemato-oncology, University Hospital Leuven, Belgium
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14
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Abstract
BACKGROUND Payment models for palliative care vary across nations, with few adopting contemporary payments designs that apply to other parts of the health system. AIM To propose optimal payment arrangements for palliative care. APPROACH Review of relevant literature on funding mechanisms in health care generally and palliative care in particular. RESULTS Payment models for palliative care should move toward activity-based funding using an agreed classification, be uncapped funding with performance monitoring, and make explicit use of performance metrics and reporting. CONCLUSIONS If palliative care is to become a universally accessible service, new approaches to funding, based on the experience of funding reforms in other parts of the health system, need to be adopted.
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Affiliation(s)
- Stephen Duckett
- Health Program, Grattan Institute, 8 Malvina Place, Carlton, VIC, 3053, Australia.
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15
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Cohen-Almagor R, Ely EW. Euthanasia and palliative sedation in Belgium. BMJ Support Palliat Care 2018; 8:307-313. [PMID: 29305500 DOI: 10.1136/bmjspcare-2017-001398] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 10/16/2017] [Accepted: 11/22/2017] [Indexed: 12/15/2022]
Abstract
The aim of this article is to use data from Belgium to analyse distinctions between palliative sedation and euthanasia. There is a need to reduce confusion and improve communication related to patient management at the end of life specifically regarding the rapidly expanding area of patient care that incorporates a spectrum of nuanced yet overlapping terms such as palliative care, sedation, palliative sedation, continued sedation, continued sedation until death, terminal sedation, voluntary euthanasia and involuntary euthanasia. Some physicians and nurses mistakenly think that relieving suffering at the end of life by heavily sedating patients is a form of euthanasia, when indeed it is merely responding to the ordinary and proportionate needs of the patient. Concerns are raised about abuse in the form of deliberate involuntary euthanasia, obfuscation and disregard for the processes sustaining the management of refractory suffering at the end of life. Some suggestions designed to improve patient management and prevent potential abuse are offered.
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Affiliation(s)
| | - E Wesley Ely
- Geriatric Research, VA Tennessee Valley Healthcare System, Education and Clinical Center (GRECC), Nashville, Tennessee, USA.,Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA.,Center for Health Services Research, Vanderbilt University, Nashville, Tennessee, USA
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16
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Dierickx S, Deliens L, Cohen J, Chambaere K. Involvement of palliative care in euthanasia practice in a context of legalized euthanasia: A population-based mortality follow-back study. Palliat Med 2018; 32:114-122. [PMID: 28849727 PMCID: PMC5758933 DOI: 10.1177/0269216317727158] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND In the international debate about assisted dying, it is commonly stated that euthanasia is incompatible with palliative care. In Belgium, where euthanasia was legalized in 2002, the Federation for Palliative Care Flanders has endorsed the viewpoint that euthanasia can be embedded in palliative care. AIM To examine the involvement of palliative care services in euthanasia practice in a context of legalized euthanasia. DESIGN Population-based mortality follow-back survey. SETTING/PARTICIPANTS Physicians attending a random sample of 6871 deaths in Flanders, Belgium, in 2013. RESULTS People requesting euthanasia were more likely to have received palliative care (70.9%) than other people dying non-suddenly (45.2%) (odds ratio = 2.1 (95% confidence interval, 1.5-2.9)). The most frequently indicated reasons for non-referral to a palliative care service in those requesting euthanasia were that existing care already sufficiently addressed the patient's palliative and supportive care needs (56.5%) and that the patient did not want to be referred (26.1%). The likelihood of a request being granted did not differ between cases with or without palliative care involvement. Palliative care professionals were involved in the decision-making process and/or performance of euthanasia in 59.8% of all euthanasia deaths; this involvement was higher in hospitals (76.0%) than at home (47.0%) or in nursing homes (49.5%). CONCLUSION In Flanders, in a context of legalized euthanasia, euthanasia and palliative care do not seem to be contradictory practices. A substantial proportion of people who make a euthanasia request are seen by palliative care services, and for a majority of these, the request is granted.
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Affiliation(s)
- Sigrid Dierickx
- 1 End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Luc Deliens
- 1 End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.,2 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- 1 End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Kenneth Chambaere
- 1 End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
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17
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Bernheim JL, Raus K. Euthanasia embedded in palliative care. Responses to essentialistic criticisms of the Belgian model of integral end-of-life care. JOURNAL OF MEDICAL ETHICS 2017; 43:489-494. [PMID: 28062650 DOI: 10.1136/medethics-2016-103511] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 10/25/2016] [Accepted: 12/01/2016] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Jan L Bernheim
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussel, Belgium
| | - Kasper Raus
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussel, Belgium
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18
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Bernheim JL, Huysmans G, Mullie A, Desmet M, Vanden Berghe P, Vander Stichele R, Deliens L. Casting Light on an Occultation in the IAHPC Position Paper on Palliative Care and Assisted Dying. J Palliat Med 2017; 20:697-698. [PMID: 28430536 DOI: 10.1089/jpm.2017.0095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jan L Bernheim
- 1 End-of-Life Care Research Group (EOLC RG), Vrije Universiteit Brussel and Ghent University , Brussels, Belgium
| | - Gert Huysmans
- 2 Federation of Palliative Care Flanders (FPCF) , Vilvoorde, Belgium
| | - Arsène Mullie
- 2 Federation of Palliative Care Flanders (FPCF) , Vilvoorde, Belgium
| | - Marc Desmet
- 3 Hospital Palliative Care Unit, Jessa Hospital , Hasselt, Belgium .,4 FPCF Steering Group for Ethics , Vilvoorde, Belgium
| | | | - Robert Vander Stichele
- 1 End-of-Life Care Research Group (EOLC RG), Vrije Universiteit Brussel and Ghent University , Brussels, Belgium
| | - Luc Deliens
- 1 End-of-Life Care Research Group (EOLC RG), Vrije Universiteit Brussel and Ghent University , Brussels, Belgium
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19
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Zenz J, Tryba M, Zenz M. Palliative care professionals' willingness to perform euthanasia or physician assisted suicide. BMC Palliat Care 2015; 14:60. [PMID: 26572742 PMCID: PMC4647811 DOI: 10.1186/s12904-015-0058-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/06/2015] [Indexed: 12/17/2022] Open
Abstract
Background Euthanasia and physician assisted suicide (PAS) are highly debated upon particularly in the light of medical advancement and an aging society. Little is known about the professionals’ willingness to perform these practices particularly among those engaged in the field of palliative care and pain management. Thus a study was performed among those professionals. Methods An anonymous questionnaire was handed out to all participants of a palliative care congress and a pain symposium in 2013. The questionnaire consisted of 8 questions regarding end of life decisions. Proposed patient vignettes were used. Results A total of 470 eligible questionnaires were returned, 198 by physicians, 272 by nurses. The response rate was 64 %. The majority of professionals were reluctant to perform euthanasia or PAS: 5.3 % of the respondents would be willing to perform euthanasia on a patient with a terminal illness if asked to do so. The reluctance grew in case of a patient with a non-terminal illness. The respondents were more willing to perform PAS than euthanasia. Nurses were more reluctant to take action as opposed to the physicians. The majority of the respondents would attempt to treat the patient’s symptoms first before considering life-ending measures. As regards any decision making process the majority would consult with a colleague. Conclusions This is the first German study to ask about the willingness of professionals to take action as regards euthanasia and PAS without biased phrasing. As opposed to the general acceptance that is respectively high, the actual willingness to perform life-ending measures is low. The German debate on physician assisted suicide and its possible legalization should also incorporate clarifications regarding the responsibility who should eventually perform these acts.
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Affiliation(s)
- Julia Zenz
- Ruhr-University Bochum, Universitätstr. 150, D 44801, Bochum, Germany.
| | - Michael Tryba
- Clinic for Anaesthesiology, Intensive Care and Pain Medicine, Moenchebergstraße 41-43, D 34125, Kassel, Germany.
| | - Michael Zenz
- Ruhr-University Bochum, Universitätstr. 150, D 44801, Bochum, Germany.
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20
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21
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Materstvedt LJ. Misconstrual of EAPC's position paper on euthanasia. JOURNAL OF MEDICAL ETHICS 2015; 41:655-656. [PMID: 25948759 DOI: 10.1136/medethics-2015-102774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 04/07/2015] [Indexed: 06/04/2023]
Abstract
This is a response to Barutta and Vollmann's article 'Physician-assisted death with limited access to palliative care.' I show how they misconstrue a key empirical statement made by the European Association for Palliative Care regarding legalisation of euthanasia and physician-assisted suicide. Additionally, I include some further remarks on the relationship between euthanasia and palliative care. I read with interest the article, which delineate well several positions and gives a nice overview of arguments presented on either side. I also found the line of argument unprejudiced and clear, and am sure people working within palliative care would benefit from reading it.
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22
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Chambaere K, Bernheim JL. Does legal physician-assisted dying impede development of palliative care? The Belgian and Benelux experience. JOURNAL OF MEDICAL ETHICS 2015; 41:657-660. [PMID: 25648645 DOI: 10.1136/medethics-2014-102116] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 01/15/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND In 2002, physician-assisted dying was legally regulated in the Netherlands and Belgium, followed in 2009 by Luxembourg. An internationally frequently expressed concern is that such legislation could stunt the development of palliative care (PC) and erode its culture. To study this, we describe changes in PC development 2005-2012 in the permissive Benelux countries and compare them with non-permissive countries. METHODS Focusing on the seven European countries with the highest development of PC, which include the three euthanasia-permissive and four non-permissive countries, we compared the structural service indicators for 2005 and 2012 from successive editions of the European Atlas of Palliative Care. As an indicator for output delivery of services to patients, we collected the amounts of governmental funding of PC 2002-2011 in Belgium, the only country where we could find these data. RESULTS The rate of increase in the number of structural PC provisions among the compared countries was the highest in the Netherlands and Luxembourg, while Belgium stayed on a par with the UK, the benchmark country. Belgian government expenditure for PC doubled between 2002 and 2011. Basic PC expanded much more than endowment-restricted specialised PC. CONCLUSIONS The hypothesis that legal regulation of physician-assisted dying slows development of PC is not supported by the Benelux experience. On the contrary, regulation appears to have promoted the expansion of PC. Continued monitoring of both permissive and non-permissive countries, preferably also including indicators of quantity and quality of delivered care, is needed to evaluate longer-term effects.
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Affiliation(s)
- Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Jan L Bernheim
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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23
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Cohen-Almagor R. First do no harm: intentionally shortening lives of patients without their explicit request in Belgium. JOURNAL OF MEDICAL ETHICS 2015; 41:625-629. [PMID: 26041861 DOI: 10.1136/medethics-2014-102387] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 05/13/2015] [Indexed: 06/04/2023]
Abstract
The aim of this article is to provide a critical review of one of the most worrying aspects of the euthanasia policy and practice in Belgium--the deliberate shortening of lives of some patients without their explicit voluntary request. Some suggestions designed to improve the situation and prevent abuse are offered.
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24
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Mortier T, Leiva R, Cohen-Almagor R, Lemmens W. Between palliative care and euthanasia. JOURNAL OF BIOETHICAL INQUIRY 2015; 12:177-178. [PMID: 25898900 DOI: 10.1007/s11673-015-9635-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 03/18/2015] [Indexed: 06/04/2023]
Affiliation(s)
- Tom Mortier
- Faculty of Management and Technology, Faculty of Health and Welfare, University Colleges Leuven-Limburg, Herestraat 49, 3000, Leuven, Belgium,
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25
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Köneke V. Trust increases euthanasia acceptance: a multilevel analysis using the European Values Study. BMC Med Ethics 2014; 15:86. [PMID: 25528457 PMCID: PMC4289573 DOI: 10.1186/1472-6939-15-86] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 12/16/2014] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND This study tests how various kinds of trust impact attitudes toward euthanasia among the general public. The indication that trust might have an impact on euthanasia attitudes is based on the slippery slope argument, which asserts that allowing euthanasia might lead to abuses and involuntary deaths. Adopting this argument usually leads to less positive attitudes towards euthanasia. Tying in with this, it is assumed here that greater trust diminishes such slippery slope fears, and thereby increases euthanasia acceptance. METHODS The effects of various trust indicators on euthanasia acceptance were tested using multilevel analysis, and data from the European Values Study 2008 (N = 49,114, 44 countries). More precisely, the influence of people's general levels of trust in other people, and their confidence in the health care system, were measured--both at the individual and at the country level. Confidence in the state and the press were accounted for as well, since both institutions might monitor and safeguard euthanasia practices. RESULTS It was shown that the level of trust in a country was strongly positively linked to euthanasia attitudes, both for general trust and for confidence in health care. In addition, within countries, people who perceived their fellow citizens as trustworthy, and who had confidence in the press, were more supportive of euthanasia than their less trusting counterparts. The pattern was, however, not true for confidence in the state and for confidence in the health care system at the individual level. Notably, all confirmative effects held, even when other variables such as religiosity, education, and values regarding autonomy were controlled for. CONCLUSIONS Trust seems to be a noteworthy construct to explain differences in attitudes towards euthanasia, especially when drawing cross-country comparisons. Therefore, it should be added to the existing literature on correlates of euthanasia attitudes.
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Affiliation(s)
- Vanessa Köneke
- Cologne Graduate School and SOCLIFE Research Training Group, University of Cologne, Albertus-Magnus-Platz, 50931 Cologne, Germany.
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26
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Zenz J, Tryba M, Zenz M. Physician-Assisted Dying: Acceptance by Physicians Only for Patients Close to Death. Pain Ther 2014; 3:103-12. [PMID: 25501920 PMCID: PMC4269613 DOI: 10.1007/s40122-014-0029-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Indexed: 02/03/2023] Open
Abstract
This study reports on German physicians' views on legalization of euthanasia and physician-assisted suicide, comparing this with a similar survey of UK doctors. A questionnaire was handed out to attendants of a palliative care and a pain symposium. Complete answers were obtained from 137 physicians. Similar to the UK study, about 30% of the physicians surveyed support euthanasia in case of terminal illness and more support physician-assisted suicide. In contrast, in both countries, a great majority of physicians oppose medical involvement in hastening death in non-terminal illnesses. The public and parliamentary discussion should face this opposition to assisted suicide by pain and palliative specialists.
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Affiliation(s)
- Julia Zenz
- Ruhr-University Bochum, Kemnaderstr. 342, 44797 Bochum, Germany
| | - Michael Tryba
- Clinic for Anaesthesiology, Intensive Care and Pain Medicine, Moenchebergstraße 41-43, 34125 Kassel, Germany
| | - Michael Zenz
- Ruhr-University Bochum, Henkenbergstr. 63, 44797 Bochum, Germany
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