Physician-Assisted Dying: Acceptance by Physicians Only for Patients Close to Death

Physicians' attitudes toward end-of-life decisions in amyotrophic lateral sclerosis

OBJECTIVE

This study aims (1) to assess physicians' attitudes toward different palliative end-of-life (EOL) practices in amyotrophic lateral sclerosis (ALS) care, including forgoing artificial nutrition and hydration (FANH), continuous sedation until death (CSD), and withdrawing invasive ventilation (WIV), and toward physician-assisted dying (PAD) including physician-assisted suicide and euthanasia and (2) to explore variables influencing these attitudes.

METHODS

We used two clinical vignettes depicting ALS patients in different stages of their disease progression to assess the influence of suffering (physical/psycho-existential) on attitudes toward WIV and the influence of suffering and prognosis (short-term/long-term) on attitudes toward FANH, CSD, and PAD.

RESULTS

50 physicians from European ALS centers and neurological departments completed our survey. Short-term prognosis had a positive impact on attitudes toward offering FANH (p = 0.014) and CSD (p = 0.048) as well as on attitudes toward performing CSD (p = 0.036) and euthanasia (p = 0.023). Predominantly psycho-existential suffering was associated with a more favorable attitude toward WIV but influenced attitudes toward performing CSD negatively. Regression analysis showed that religiosity was associated with more reluctant attitudes toward palliative EOL practices and PAD, whereas training in palliative care was associated with more favorable attitudes toward palliative EOL practices only.

CONCLUSION

ALS physicians seem to acknowledge psycho-existential suffering as a highly acceptable motive for WIV but not CSD. Physicians appear to be comfortable with responding to the patient's requests, but more reluctant to assume a proactive role in the decision-making process. Palliative care training may support ALS physicians in these challenging situations.

Survey on German Palliative Care Specialists' Experiences with Advance Directives

Introduction

Advance directives (AD) play a central role in end-of-life treatments, intensive care, and palliative care. However, little is known about the experiences of healthcare professionals with ADs. This study reports on palliative care professionals’ views on advance directives (AD).

Methods

A questionnaire was handed out to attendants of a palliative care symposium.

Results

Complete answers were obtained from 126 physicians and 276 nurses. Almost all physicians and nurses had treated patients with an AD, and the majority more than 10 patients. The most frequent refusal by the patients was resuscitation (87.8%) followed by intensive care (79.1%), artificial ventilation, and nutrition. The most frequent wish was pain therapy (92.3%) followed by allowing the natural course of the illness (64.4%). The wish for hospice treatment (44.8%) or spiritual care (39.3%) was less frequent.

Discussion

The results hint at fears and deficits in the care of patients at the end of life. Often the quality of life and not the quantity of days remaining is in the center of a patient’s will and points to the growing importance of palliative care.

Conclusion

ADs are well established among palliative care professionals and regarded as helpful for patients at the end of life.

Palliative care professionals' willingness to perform euthanasia or physician assisted suicide

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.