Ethische Entscheidungen am Lebensende - Kenntnisstand und Einstellungen Medizinstudierender

Physician-assisted suicide, euthanasia and palliative sedation: attitudes and knowledge of medical students

OBJECTIVES

In November 2015, the German Federal Parliament voted on a new legal regulation regarding assisted suicide. It was decided to amend the German Criminal Code so that any "regular, repetitive offer" (even on a non-profit basis) of assistance in suicide would now be considered a punishable offense. On July 2, 2015, a date which happened to be accompanied by great media interest in that it was the day that the first draft of said law was presented to Parliament, we surveyed 4th year medical students at the Technical University Munich on "physician-assisted suicide," "euthanasia" and "palliative sedation," based on a fictitious case vignette study.

METHOD

The vignette study described two versions of a case in which a patient suffered from a nasopharyngeal carcinoma (physical suffering subjectively perceived as being unbearable vs. emotional suffering). The students were asked about the current legal norms for each respective course of action as well as their attitudes towards the ethical acceptability of these measures.

RESULTS

Out of 301 students in total, 241 (80%) participated in the survey; 109 answered the version 1 questionnaire (physical suffering) and 132 answered the version 2 questionnaire (emotional suffering). The majority of students were able to assess the currently prevailing legal norms on palliative sedation (legal) and euthanasia (illegal) correctly (81.2% and 93.7%, respectively), while only a few students knew that physician-assisted suicide, at that point in time, did not constitute a criminal offense. In the case study that was presented, 83.3% of the participants considered palliative sedation and the simultaneous withholding of artificial nutrition and hydration as ethically acceptable, 51.2% considered physician-assisted suicide ethically legitimate, and 19.2% considered euthanasia ethically permissible. When comparing the results of versions 1 and 2, a significant difference could only be seen in the assessment of the legality of palliative sedation: it was considered legal more frequently in the physical suffering version (88.1% vs. 75.8%).

CONCLUSION

The majority of the students surveyed wrongly assumed that physician-assisted suicide is a punishable offense in Germany. However, a narrow majority considered physician-assisted suicide ethically acceptable in the case study presented. Compared to euthanasia, more than twice as many participants considered physician-assisted suicide acceptable. There was no significant difference between personal attitudes towards palliative sedation, physician-assisted suicide or euthanasia in light of physical or emotional suffering. Educational programs in this field should be expanded both qualitatively and quantitatively, especially considering the relevance of the subject matter, the deficits within the knowledge of legal norms and the now even higher complexity of the legal situation due to the new law from December 2015.

Knowledge and attitude of final - year medical students in Germany towards palliative care - an interinstitutional questionnaire-based study

BACKGROUND

To care for terminally ill and dying patients requires a thorough medical education, encompassing skills, knowledge, and attitudes in the field of palliative care. Undergraduate medical students in Germany will receive mandatory teaching in palliative care in the near future driven by recent changes in the Medical Licensure Act. Before new curricula can be implemented, the knowledge of medical students with respect to palliative care, their confidence to handle palliative care situations correctly, their therapeutic attitude, and their subjective assessment about previous teaching practices have to be better understood.

METHOD

We designed a composite, three-step questionnaire (self estimation of confidence, knowledge questions, and opinion on the actual and future medical curriculum) conducted online of final - year medical students at two universities in Germany.

RESULTS

From a total of 318 enrolled students, 101 responded and described limited confidence in dealing with specific palliative care issues, except for pain therapy. With regard to questions examining their knowledge base in palliative care, only one third of the students (33%) answered more than half of the questions correctly. Only a small percentage of students stated they had gained sufficient knowledge and experience in palliative care during their studies, and the vast majority supported the introduction of palliative care as a mandatory part of the undergraduate curriculum.

CONCLUSION

This study identifies medical students' limited confidence and knowledge base in palliative care in 2 German universities, and underlines the importance of providing a mandatory palliative care curriculum.

Attitudes toward active euthanasia among medical students at two German universities

AIM

There has been an ongoing debate about a legalisation of active euthanasia (AE) in Germany. Palliative care education in German medical schools seeks to foster and cultivate a negative attitude toward AE, but little is known about its effectiveness in this respect. The aim of this study was to assess attitudes toward AE among students with and without palliative medicine tuition (PMT).

METHODS

The link to an anonymised online questionnaire was sent out to 1,092 third, fifth and sixth year medical students (YMS) in August-November 2006 at two German universities: university one (U1) with compulsory and additional optional PMT and university two (U2) without any PMT. Thirteen questions addressed active, passive or indirect euthanasia and physician-assisted suicide (statistic: mean +/- SD (range), Wilcoxon, Whitney U Test, significance p < 0.05).

RESULTS

Response rate was 17.5%; 59.2% of the questionnaires were returned from U1 and 40.8% from U2; 28.3% of the students were male. Whereas 50% of third YMS at U1 and 36.7% at U2 favoured a legalisation of AE, this was true for 22.4% sixth YMS at U1 and 35.7% at U2. At U1, the number of students who would want to make use of AE for themselves decreased considerably (70%-44.9%) but less at U2; main reasons were 'unbearable suffering' and 'circumstances that lack dignity'. Of all students, 21.1% at U1 and 37.2% at U2 could imagine to perform AE in patients, even though 72.6% at U1 and 78.2% at U2 think its legalisation would promote misuse.

CONCLUSIONS

The high proportion of pro-AE attitudes gives reason to reconsider both 'standard' and palliative medicine tuition for medical students.

Survey of Palliative Care Concepts among Medical Students and Interns in Austria: A Comparison of the Old and the New curriculum of the Medical University of Vienna

Background

To improve the level of awareness in palliative care concepts, the new curriculum at the University of Vienna includes sixteen hours of palliative care education. The old curriculum did not include palliative care education.

Aim

To compare the level of awareness in palliative care concepts among 4th year students of the new curriculum of the Medical University of Vienna with interns who finished their studies in the old curriculum. Materials and methods: 440 medical students in their 4th year and 149 interns participated in a survey study. Data were collected after the survey and the responses were analyzed.

Results

Data analysis consists of completed survey obtained from 83% and 67% of the students and interns. We observed that students reported higher theoretical knowledge of palliative care concepts as compared to interns, whereas interns were better in performing practical aspects of palliative care. A significant percentage of students and interns would like to learn more about palliative care in their curriculum, although this was more present among interns (72.7% students and 92.6% interns, p < 0.0001, respectively).

Conclusion

Although palliative care education is already included in a compulsory manner in the new curriculum of the Medical University of Vienna, almost two third of all students would support more implementation of palliative care issues throughout the curriculum. To further improve attitudes and skills towards patients at end of life, palliative care education should be augmented in the new curriculum.