"An indelible mark" the response to participation in euthanasia and physician-assisted suicide among doctors: A review of research findings

Psychological stress of general practitioners in the care of patients with palliative care needs: an exploratory study

BACKGROUND

In Germany, general practitioners play a pivotal role in palliative care provision. Caring for patients with palliative care needs can be a burden for general practitioners, highlighting the importance of self-care and mental health support. This study aimed to explore the role of palliative care in general practitioners' daily work, the stressors they experience, their coping mechanisms, and the potential benefits of Advance Care Planning in this context.

METHODS

An exploratory approach was employed, combining a short quantitative survey with qualitative interviews. The analysis was based on a structuring qualitative content analysis, following a deductive-inductive procedure and integrating the Stress-Strain Model and Lazarus' Transactional Model of Stress and Coping. We recruited eleven general practitioners to take part in the study.

RESULTS

General practitioners viewed palliative care as integral to their practice but faced challenges such as time constraints and perceived expertise gaps. Societal taboos often hindered conversations on the topic of death. Most general practitioners waited for their patients to initiate the topic. Some general practitioners viewed aspects of palliative care as potentially distressing. They used problem-focused (avoiding negative stressors, structuring their daily schedules) and emotion-focused (discussions with colleagues) coping strategies. Still, general practitioners indicated a desire for specific psychological support options. Advance Care Planning, though relatively unfamiliar, was acknowledged as valuable for end-of-life conversations.

CONCLUSIONS

Palliative care can be associated with negative psychological stress for general practitioners, often coming from external factors. Despite individual coping strategies in place, it is advisable to explore concepts for professional psychological relief.

TRIAL REGISTRATION

Not registered.

Facing a request for assisted death - views of Finnish physicians, a mixed method study

BACKGROUND

Assisted death, including euthanasia and physician-assisted suicide (PAS), is under debate worldwide, and these practices are adopted in many Western countries. Physicians' attitudes toward assisted death vary across the globe, but little is known about physicians' actual reactions when facing a request for assisted death. There is a clear gap in evidence on how physicians act and respond to patients' requests for assisted death in countries where these actions are not legal.

METHODS

A survey including statements concerning euthanasia and PAS and an open question about their actions when facing a request for assisted death was sent to all Finnish physicians. Quantitative data are presented as numbers and percentages. Statistical significance was tested by using the Pearson chi-square test, when appropriate. The qualitative analysis was performed by using an inductive content analysis approach, where categories emerge from the data.

RESULTS

Altogether, 6889 physicians or medical students answered the survey, yielding a response rate of 26%. One-third of participants agreed or partly agreed that they could assist a patient in a suicide. The majority (69%) of the participants fully or partly agreed that euthanasia should only be accepted due to difficult physical symptoms, while 12% fully or partly agreed that life turning into a burden should be an acceptable reason for euthanasia. Of the participants, 16% had faced a request for euthanasia or PAS, and 3033 answers from 2565 respondents were achieved to the open questions concerning their actions regarding the request and ethical aspects of assisted death. In the qualitative analysis, six main categories, including 22 subcategories, were formed regarding the phenomenon of how physicians act when facing this request. The six main categories were as follows: providing an alternative to the request, enabling care and support, ignoring the request, giving a reasoned refusal, complying with the request, and seeing the request as a possibility.

CONCLUSIONS

Finnish physicians' actions regarding the requests for assisted death, and attitudes toward euthanasia and PAS vary substantially. Open discussion, education, and recommendations concerning a request for assisted death and ethics around it are also highly needed in countries where euthanasia and PAS are not legal.

Words matter: 'enduring intolerable suffering' and the provider-side peril of Medical Assistance in Dying in Canada

Enduring intolerable suffering, an essential eligibility criterion in Medical Assistance in Dying (MAiD) in Canada and elsewhere, is a contradiction in terms, in that suffering must be tolerable to be endured. Cases of people who were approved for MAiD but who elected to die naturally, thus tolerating their suffering, bear out the unreliability of this central safeguard. The clinical assessment of intolerable suffering may be strengthened by adopting a definition of intolerable suffering centred on clinically evidenced physical and psychological decompensation. This argument also raises important questions about the risks of MAiD clinicians subjectively defining, approving and providing MAiD in ways that deviate from accepted legal and clinical concepts and ethics. Examples show some prolific clinicians describe MAiD in terminology that differs from such norms, as a personal mission, as personally pleasurable, and as a rights-based service. These alternative views are explored for their risks in assessing and providing MAiD for intolerable suffering. This further demonstrates the need for conceptual clarity in legislation, improved vetting and monitoring of clinicians, and a different assessment process to protect patients and clinicians.

[The euthanasia law and professional experiences: tensions in clinical practice]

OBJECTIVE

To analyze the process of assisted death provision in Catalonia and identify the main tensions, difficulties, and/or sources of discomfort related to professional practice.

METHOD

A qualitative study was conducted based on interviews (n=29) and focus groups (n=19) with professionals who participated in the euthanasia process. The selection of participants combined the snowball and maximization of variability procedures, taking into account the variables of professional profile, setting, gender, age and territoriality. Intentional and theoretical sampling process.

RESULTS

The assisted death process is divided into four main moments: 1) reception of the request, 2) medical-bureaucratic procedure, 3) the actual procedure, and 4) closure. At each of these moments, difficulties arise that can be a source of discomfort and have to do with the limits and tensions between the legal and moral, the conception of one's own professional role, the lack of recognition of some professional roles, stress and overload, the lack of formal and informal support, and the relationship with the patient and his/her family. The bureaucratic-administrative stress derived from a protective law, with both prior and subsequent verifying control, stands out, given that it stresses the professionals immersed in a healthcare system already under high pressure after budget cuts and the COVID-19 epidemic.

CONCLUSIONS

Throughout the assisted death process, the sources of distress are diverse and of a psychological, psychosocial, and structural nature. These results may lead to interventions for psychological and peer support, information, training, institutional involvement, and burden reduction.

Personality traits and attitude towards euthanasia among medical students in Serbia

OBJECTIVE

Various factors may influence the attitudes of medical students towards euthanasia, including personal values, beliefs, and personality traits. The objective of this study was to examine the attitudes of 2nd and 5th year medical students about euthanasia and the relationship between these attitudes and students' personality traits.

METHODS

Medical students from the Universities of Kragujevac and Belgrade, Serbia, participated in this study. A questionnaire was administered assessing attitudes toward euthanasia and student personality traits (honesty-humility, emotionality, extraversion, agreeableness, conscientiousness, and openness using the HEXACO-60).

RESULTS

More than 50% of students in the second year and 60% of students in the fifth year were supportive of euthanasia. Students in the 5th year were 2.5 times more likely to express a concern that euthanasia needs to be clearly regulated by law compared to students in the second year. Adjusted analyses indicated that lower levels of honesty-humility and emotionality were positively correlated with students' belief that euthanasia should be legalized.

CONCLUSION

Many medical students in Serbia have a positive attitude towards euthanasia. It is important to consider the possible influences of culture, religion, and the law on attitudes towards euthanasia. Undergraduate medical training should include more hours dedicated to palliative care and end-of-life topics to raise awareness of patients' preferences in this regard.

Is medical assistance in dying just medically-administered death?

As medical assistance in dying seemingly gains traction, this editorial discusses the arguments for and against it, looking at the balance of patient autonomy and alleviation of suffering vs the potentially far-reaching and unintended consequences. The authors hope that this provides a platform for further debate and education around assisted dying.

Assisted dying and medical practice: questions and considerations for healthcare organisations

OBJECTIVES

Most clinical teams and organisations have not openly or formally discussed how they would react if physician-assisted suicide were to be legalised. This paper aims to discuss some of the potential challenges of introducing 'assisted dying' into medical care and produces a table of questions and considerations in light of such evidence so as to promote necessary discussion.

METHODS

An analysis of recent quantitative and qualitative studies from jurisdictions where 'assisted dying' is practised was conducted, with particular attention paid to studies which focus on the impact of legalising 'assisted dying' on clinical care.

RESULTS

'Assisted dying' can have a significant impact on clinical practice by complicating patient care and increasing clinician workload, potentially causing stress on patient care.

CONCLUSIONS

If physician-assisted suicide was to be legalised as part of existing healthcare, there are many questions that healthcare organisations must consider. Such considerations are tabulated in order to encourage awareness and discussion on the topic.

Relatives' Experiences of Being Involved in Assisted Dying: A Qualitative Study

Recent literature demonstrates an interdependence between relatives and healthcare providers throughout euthanasia processes. Yet, current guidelines and literature scarcely specify the interactions between healthcare providers and bereaved relatives. The aim of this work consisted of providing an insight into bereaved relatives' experiences (1) of being involved in euthanasia processes and (2) of their interactions with healthcare providers before, during, and after the euthanasia. The research process was guided by the principles of constructivist grounded theory. Nineteen Dutch-speaking bereaved relatives of oncological patients, who received euthanasia at home or in a hospital less than 24 months ago, participated via semi-structured interviews. These interviews were conducted between May 2021 and June 2022. Due to the intensity of euthanasia processes, relatives wanted to be involved as early as possible, in order to receive time, space, and access to professionals' support whilst preparing themselves for the upcoming loss of a family member with cancer. Being at peace with the euthanasia request facilitated taking a supportive attitude, subsequently aiding in achieving a serene atmosphere. A serene atmosphere facilitated relatives' grief process because it helped them in creating and preserving good memories. Relatives appreciated support from healthcare providers, as long as overinvolvement on their part was not occurring. This study advocates for a relational approach in the context of euthanasia and provides useful complements to the existing euthanasia guidelines.

Moral uncertainty and distress about voluntary assisted dying prior to legalisation and the implications for post-legalisation practice: a qualitative study of palliative and hospice care providers in Queensland, Australia

OBJECTIVES

There is little research on moral uncertainties and distress of palliative and hospice care providers (PHCPs) working in jurisdictions anticipating legalising voluntary assisted dying (VAD). This study examines the perception and anticipated concerns of PHCPs in providing VAD in the State of Queensland, Australia prior to legalisation of the practice in 2021. The findings help inform strategies to facilitate training and support the health and well-being of healthcare workers involved in VAD.

DESIGN

The study used a qualitative approach to examine and analyse the perception and anticipated concerns of PHCPs regarding challenges of providing assisted dying in Queensland. Fourteen PHCPs were recruited using a purposive sampling strategy to obtain a broad representation of perspectives including work roles, geographical locations and workplace characteristics. Data were collected via one in-depth interview per participant. The transcripts were coded for patterns and themes using an inductive analysis approach following the tradition of Grounded Theory.

SETTING

The study was conducted in hospital, hospice, community and residential aged care settings in Queensland, Australia. These included public and private facilities, secular and faith-based facilities, and regional/rural and urban facilities.

PARTICIPANTS

Interviews were conducted with fourteen PHCPs: 10 nurses and 4 physicians; 11 female and 3 male. The median number of years of palliative care practice was 17, ranging from 2 to 36 years. For inclusion, participants had to be practising palliative and hospice care providers.

RESULTS

PHCPs are divided on whether VAD should be considered part of palliative care. Expectations of moral distress and uncertainty about practising VAD were identified in five areas: handling requests, assessing patient capacity, arranging patient transfers and logistical issues, managing unsuccessful attempts, and dealing with team conflicts and stigma.

CONCLUSIONS

The possibility of having to practise VAD causes moral distress and uncertainty for some PHCPs. Procedural clarity can address some uncertainties; moral and psychological distress, however, remains a source of tension that needs support to ensure ongoing care of both patients and PHCPs. The introduction of VAD post-legalisation may present an occasion for further moral education and development of PHCPs.

Bereavement care and the interaction with relatives in the context of euthanasia: A qualitative study with healthcare providers

BACKGROUND

A recent review shows an interdependence between healthcare providers and relatives in the context of euthanasia. Belgian guidelines do focus on the role of certain healthcare providers (physicians, nurses, and psychologists), yet they hardly specify bereavement care services before, during and after the euthanasia.

PURPOSE

A conceptual model showing underlying mechanisms of healthcare providers' experiences regarding the interaction with and the provision of bereavement care to relatives of cancer patients throughout a euthanasia process.

METHODS

47 semi-structured interviews with Flemish physicians, nurses and psychologists working in hospitals and/or homecare, conducted from September 2020 to April 2022. Transcripts were analyzed using the Constructivist Grounded Theory Approach.

RESULTS

Participants experienced the interaction with relatives as very diverse, which can be visualized as a continuum ranging from negative to positive, depending on each unique case. The achieved degree of serenity was the main contributor in determining their position on the aforementioned continuum. To create this serene atmosphere, healthcare providers undertook actions underpinned by two attitudes (wariness and meticulousness), which are guided by different considerations. These considerations can be categorized into three groups: 1) ideas about a good death and its importance, 2) having the situation well under control and 3) self-reassurance.

CONCLUSIONS

If relatives were not at peace, most participants said that they deny a request or formulate additional requirements. Moreover, they wanted to ensure relatives can cope with the loss, which was often experienced as intense and time-consuming. Our insights shape needs-based care from healthcare providers' perspective in the context of euthanasia. Future research should explore the relatives' perspective regarding this interaction and the provision of bereavement care.

TWEETABLE ABSTRACT

Professionals strive for a serene atmosphere throughout a euthanasia process to ensure relatives can cope with the loss, and the way in which the patient died.

Analysing the Assisted Dying Bill [HL] debate 2021

This paper considers the number of speeches which treat central topics in the House of Lords second reading of the 'Assisted Dying Bill' (October 22, 2021). It summarizes some of the principal arguments for and against the Bill according to the main categories of discussion. These were compassion; palliative care; autonomy, choice and control; legal and social effects. In summarizing the arguments thematically, it is possible to see the current state of the debate and how concerns are shared on either side, even if approaches to and proposed solutions for those problems are different. The paper concludes that the essential source of disagreement lies outside of the arguments raised, and therefore that any change in the law is not likely to arise from political consensus.

Eutanasia y Psicología. Algunas claves para la intervención en Procesos Adelantados de Muerte

Los países que han optado por regular los Procesos Adelantados de Muerte (PAM) van en aumento en los últimos años. Este tipo de legislaciones implican directamente a los equipos sanitarios.Los psicólogos incluidos en estos equipos están en contacto con estos procesos, por lo que se torna imprescindible dilucidar, mediante la escasa literatura existente, si los PAM presentan variables diferenciales con otros procesos de muerte, que sean necesarias tener en cuenta durante la asistencia psicológica. Esta recopilación de literatura pretende plantear las diferencias que en la actualidad están contrastadas y plantear qué opciones de intervención psicológica están a nuestra disposición para realizar el acompañamiento a estas personas, sus cuidadores y los equipos sanitarios que los asisten.

Introducing Medical Assistance in Dying in Canada: Lessons on Pragmatic Ethics and the Implementation of a Morally Contested Practice

Medical Assistance in Dying (MAiD) in Canada has had a tumultuous social and legal history. In the 6 years since assisted dying was decriminalized by the Canadian Parliament in June 2016, the introduction of this practice into the Canadian healthcare system has been fraught with ethical challenges, practical hurdles and grass-roots innovation. In 2021, MAiD accounted for approximately 3.3% of all Canadian deaths annually, and more patients are seeking MAiD year over year as this option becomes more widely know. Unfortunately, some patients who want MAiD are unable to access it in a timely manner because of a lack of willing MAiD providers. This introduction describes statistics about the uptake of MAiD in Canada and the challenges presented by Canadians’ rapid acceptance of this end of life care option. In this special edition of HEC Forum about the implementation of MAiD in Canada, authors depict a range of ethical challenges and strategies to address issues related to MAiD access and quality, organizational engagement, clinician recruitment and retention, and support for a morally diverse workforce. In each article, the authors reflect on the question: What are the practical ethics involved in introducing assisted dying into a new healthcare context, and how can ethicists and ethics resources collaborate with stakeholders to ensure the integration of ethical considerations as this practice continues to evolve?

Assisted dying request assessments by trained consultants: changes in practice and quality - Repeated cross-sectional surveys (2008-2019)

OBJECTIVES

To study changes in the peer consultation practice of assessing assisted dying requests and its quality among trained 'Life End Information Forum' (LEIF) consultants in Belgium between 2008 and 2019.

METHODS

Cross-sectional surveys conducted in 2008 (N=132) and 2019 (N=527) among all registered LEIF consultants.

RESULTS

The response rate was 75% in 2008 and 57% in 2019. In 2019 compared with 2008, more LEIF consultants were significantly less than 40 years old (25%/10%, p=0.006) and at least 60 years old (34%/20%, p=0.006). In their activities regarding assessments of assisted dying requests over 12 months, we found a significant increase in the number of patients who did not meet the substantive requirements for assisted dying in 2019 compared with 2008 (1-4 patients: 41.1 %/58.8%, p=0.020). In their most recent assessments of an assisted dying request, LEIF consultants in 2019 made significantly more assessments of patients aged 80 years or older than in 2008 (31%/9%, p<0.001), and significantly fewer assessments for patients with cancer (53%/70%, p=0.034). Regarding adherence to quality criteria for consultation, LEIF consultants discussed unbearable suffering (87%/65%, p=0.003) and alternative treatments (palliative: 48 %/13%, p<0.001; curative: 28%/5%, p=0.002) significantly more often with the attending physician.

CONCLUSIONS

Changes in peer consultation practice and its quality among LEIF consultants likely reflect changes in assisted dying practice in general, as well as changes in LEIF consultations on more complex cases for which LEIF consultants' expertise is required.

Debating Euthanasia and Physician-Assisted Death in People with Psychiatric Disorders

PURPOSE OF REVIEW

Over the last 30 years, medical assistance in dying (MAiD) including euthanasia (EU) and physician-assisted death (or suicide, PAS) has become the center of a large debate, particularly when these practices have involved people with psychiatric illness, including resistant depression, schizophrenia, personality, or other severe psychiatric disorders. We performed a review utilizing several databases, and by including the most relevant studies in full journal articles investigating the problem of MAiD in patients with psychiatric disorders but not in physical terminal conditions (non-terminal, MAiD-NT).

RECENT FINDINGS

Literature has shown that a small percentage of people with psychiatric disorders died by MAiD-NT in comparison with patients with somatic diseases in terminal clinical conditions (e.g., cancer, AIDS). However, the problem in the field is complex and not solved yet as confirmed by the fact that only a few countries (e.g., the Netherlands, Belgium, Luxemburg) have legalized MAiD-NT for patients with psychiatric disorders, while most have maintained the practices accessible only to people with somatic disease in a terminal phase. Also, how to make objective the criterion of irremediability of a mental disorder; how to balance suicide prevention with assisted suicide; how to avoid the risk of progressively including in requests for MAiD-NT vulnerable segments of the population, such as minors, elderly, or people with dementia, in a productive-oriented society, are some of the critical points to be discussed. The application of MAiD-NT in people with psychiatric disorders should be further explored to prevent end-of-life rights from contradicting the principles of recovery-oriented care.

What the Doctor Would Prescribe: Physician Experiences of Providing Voluntary Assisted Dying in Australia

BACKGROUND

Like many countries where voluntary assisted dying (VAD) is legal, eligible doctors in Victoria, Australia, have sole legal authority to provide it. Doctors' attitudes towards legalised VAD have direct bearing on their willingness to participate in VAD and consequently, on whether permissive laws can effectively facilitate access to VAD. The study aimed to explore how some Victorian doctors are perceiving and experiencing the provision of legalised VAD under a recently commenced law.

METHODS

Semi-structured interviews with 25 Victorian doctors with no in-principle objection to legalised VAD were conducted between July 2019-February 2020. Interviews were recorded, transcribed, and analysed using thematic analysis. Ethical approval from the relevant institution was obtained.

RESULTS

Doctors perceive or experience VAD to fundamentally challenge traditional medical practice. Barriers to access to VAD derive from applicant, communication, and doctor-related factors. Doctors' willingness to participate in VAD is situation specific.