A national survey of physician-assisted suicide and euthanasia in the United States

Meaning-centered pain coping skills training for patients with metastatic cancer: Protocol for a randomized controlled efficacy trial

BACKGROUND

Many patients with advanced cancer describe pain as a debilitating symptom that greatly interferes with daily activities and enjoyment of life. Psychosocial interventions can improve cancer-related pain but rarely address spiritual concerns (e.g., loss of meaning, peace), which can influence the pain experience for those facing life-threatening illness. To address these needs, we systematically developed and pilot tested a novel psychosocial intervention called Meaning-Centered Pain Coping Skills Training (MCPC). In this randomized controlled trial, we aim to determine MCPC's efficacy for reducing pain interference (primary outcome) and improving secondary outcomes. We will also estimate MCPC's cost-effectiveness.

METHOD/DESIGN

Patients (target N = 210) with advanced solid tumor malignancies (Stage IV) and clinically-elevated pain interference will be enrolled and block randomized with equal allocation to MCPC + enhanced usual care or enhanced usual care alone. MCPC's four, videoconferenced, 45-60 min weekly sessions will be individually delivered by trained study therapists. Primary (pain interference) and secondary (pain severity, anxiety and depressive symptoms, pain self-efficacy, social support, spiritual well-being) patient-reported outcomes will be assessed at baseline, and 8-weeks (primary endpoint) and 12-weeks after baseline.

CONCLUSION

Our MCPC intervention is the first to systematically address the biopsychosocial-spiritual aspects of pain in patients with advanced cancer. If MCPC demonstrates efficacy, next steps will involve hybrid efficacy-effectiveness and implementation work to broaden access to this brief, manualized, remotely-delivered intervention, with the goal of reducing suffering in patients with life-threatening illness.

Ethical considerations in the relief of cancer pain

The management of pain for patients with cancer and cancer survivors is a critical clinical task that involves a multitude of ethical issues at almost every phase of the cancer experience. This review is divided into three sections: In the first, we address rights and duties in the relief of pain from the perspective of patients, clinicians, health care institutions and organizations, and public policy. This section includes a detailed description of issues and duties in relation to opioid misuse and addiction. In the second section, we discuss the ethical consideration of therapeutic planning. The final section addresses ethical considerations in the management of pain at the end of life including a detailed discussion regarding ethical issues relating to the use of palliative sedation as a clinical intervention of last resort.

A Systematic Review of Stakeholder Perspectives of Dignity and Assisted Dying

INTRODUCTION

The debate on assisted dying and its components, euthanasia and physician-assisted suicide has evolved with the emergence of the right to dignity and the wish to hasten death (WTHD). Whilst shaped by local legal and sociocultural considerations, appreciation of how patients, healthcare professionals and lawmakers relate notions of dignity to self-concepts of personhood and the desire for assisted dying will better inform and direct support of patients.

METHODS

Guided by the Systematic Evidence Based Approach, a systematic scoping review (SSR in SEBA) on perspectives of dignity, WTHD and personhood featured in PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Scopus databases and four key Palliative Care journals was conducted. The review hinged on the following questions: "what is the relationship between dignity and the wish to hasten death (WTHD) in the assisted dying debate?", "how is dignity conceptualised by patients with WTHD?" and "what are prevailing perspectives on the role of assisted dying in maintaining a dying patient's dignity?"

RESULTS

6947 abstracts were identified, 663 full text articles reviewed, and 88 articles included. The four domains identified include 1) concepts of dignity through the lens of the Ring Theory of Personhood (RToP) including their various definitions and descriptions; 2) the relationship between dignity, WTHD and assisted dying with loss of dignity and autonomy foregrounded; 3) stakeholder perspectives for and against assisted dying including those of patient, healthcare provider and lawmaker; and 4) other dignity-conserving measures as alternatives to assisted dying.

CONCLUSION

Concepts of dignity constantly evolve throughout the patient's end of life journey. Understanding when and how these concepts of personhood change and trigger the fear of a loss of dignity or intractable suffering could direct timely, individualised and appropriate person-centred dignity conserving measures. We believe an RToP-based tool could fulfil this role and further study into the design of this tool is planned.

Euthanasia - Review and update through the lens of a psychiatrist

Euthanasia is not infrequent in the modern practice of medicine. Active euthanasia is legal in seven countries worldwide and passive euthanasia has recently been legalized in India by the Supreme Court. In India, physicians and nurses generally have a favorable attitude towards euthanasia but lack in adequate training to deal with such requests. The role of a psychiatrist is very important in evaluation of request for euthanasia on medical as well as psychiatric grounds. Among patients with end-stage medical illnesses who make a request for euthanasia or physician-assisted suicide, many may have underlying untreated depression. In the complex backdrop of long-term chronic medical illnesses, depression can be very difficult to diagnose and treat. Patients with dementia and other neuropsychiatric illnesses have the issue of consent and capacity. Legalizing euthanasia in these patients can heave dire moral implications. There is clear need of adequate training, formulation of guidelines, and supportive pathway for clarity of clinicians regarding euthanasia in India.

Assessment of Oncology Advanced Practice Professional Willingness to Participate in Medical Aid in Dying

IMPORTANCE

In 2021, New Mexico passed legislation allowing nurse practitioners and physician assistants (referred to herein as advanced practice professionals [APPs]) to prescribe medications for medical aid in dying (MAID). Other US states with existing MAID laws (eg, Washington) are also considering expanding MAID prescribing authority to APPs. There is a lack of research exploring APP knowledge of, willingness to, and comfort with acting as a prescribing or consulting clinician for MAID.

OBJECTIVE

To assess perspectives of oncology APPs regarding MAID, including their willingness to prescribe and/or consult for MAID and factors associated with willingness.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, self-report survey study used data collected from APPs working at a comprehensive cancer center in Washington State in fall 2021.

MAIN OUTCOMES AND MEASURES

The primary survey question was whether APPs would be willing to participate in death with dignity, the term used for MAID in Washington. Survey questions evaluated how influential specific factors were on APP views on MAID as well as respondents' knowledge of and comfort with aspects of the MAID process.

RESULTS

Of 167 eligible APPs, 77 (46.1%) responded to the survey. Most respondents (68 [88.3%]) reported their race and ethnicity as White; 72 (93.5%) identified as a woman. Medical oncology (28 [36.4%]) was the most common field of practice, and 21 respondents (27.3%) reported having practiced as an APP for 6 to 10 years. Of all respondents, 61 (79.2%) reported having at least 1 patient who inquired about MAID; depending on the question, less than a third of respondents (5.0%-27.0%) endorsed feeling knowledgeable or very knowledgeable about any aspect of the MAID process. In this study, 39 APPs (50.6%) endorsed being willing to participate in MAID either as a consulting or prescribing clinician, whereas 31 (40.3%) were uncertain of whether they would participate. Willingness to participate was associated with having had more patients pursue MAID (33 of the 39 willing participants [84.6%] vs 15 of the 31 unsure participants [48.4%] reported having 1 or more patients pursue MAID). Higher knowledge and comfort scores were both significantly associated with increased odds of being willing to participate (odds ratio, 1.14 per 1-point score increase [95% CI, 1.03-1.27]; P = .01) vs unsure (1.18 [95% CI, 1.07-1.30; P = .001).

CONCLUSIONS AND RELEVANCE

The results of this survey study suggest that oncology APPs may require preparation for the addition of MAID to their scope of practice. This study also raises questions for future research regarding support for APPs who may be considering participation in MAID but question their role or want physician involvement.

Physicians' Attitudes and Experiences with Medical Aid in Dying in Colorado: a "Hidden Population" Survey

BACKGROUND

Approximately 20% of the US population live in states where MAiD is a legal, though highly contentious, practice. Little generalizable data exists on the experiences of MAiD providers who comprise a small, and intentionally hidden, population.

OBJECTIVE

To examine the nature, extent, and consequences of physicians' participation in MAiD.

DESIGN

An anonymous, multi-wave, mailed survey (RR= 55%).

PARTICIPANTS

An enriched sample (n=583) of Colorado physicians caring for potential MAiD patients.

MAIN MEASURES

Physician willingness, preparedness, and participation in a continuum of MAiD activities. Other outcomes include the effects of providing MAiD and the barriers physicians face related to MAiD.

KEY RESULTS

Overall, 81.1% of respondents were willing to discuss MAiD with a patient, 88.3% to refer for MAiD, 46.3% to be a consultant, and 28.1% to be an attending. Fewer felt prepared to discuss MAiD (54.4%), provide a MAiD referral (62.8%), be a consultant (30.7%), or be an attending (18.0%). More than half of respondents (52.3%) had discussed MAiD with a patient, 27.3% provided a MAiD referral, 12.8% had been a MAiD consultant, and 8.5% had been a MAiD attending. Among MAiD consultants and attendings, 75% reported that their most recent MAiD case was emotionally fulfilling and professionally rewarding, though 75% also reported that it was time consuming and 46.9% reported that it was ethically challenging. Common barriers to physician participation in MAiD include lack of knowledge about MAiD (46.8%), the emotional (45.6%) and time (41.7%) investments, and ethical concerns (41.7%).

CONCLUSIONS

Many physicians in our sample are both willing and prepared to discuss MAiD with patients and to provide MAiD referrals. Fewer are prepared and willing to serve as an attending or consultant and fewer have provided these services. MAID consultants and attendings largely report the experience to be emotionally fulfilling and professionally rewarding, but all respondents reported multiple barriers to participation.

Evaluating requests for physician-assisted suicide. A survey among German oncologists

BACKGROUND

Cancer patients form a notable proportion of requestors for physician-assisted suicide (PAS). This manuscript provides data on German oncologists' views concerning due criteria for the assessment of requests for PAS and quality assurance.

METHODS

The German Society of Haematology and Medical Oncology (DGHO) has conducted a survey among its members to elicit data about practices and views on regulating PAS in March 2021. Descriptive analysis and bivariate logistic regression of quantitative data on socio-demographic and other determinants possibly associated with respondents' views on PAS as well as content analysis of qualitative data were performed.

RESULTS

About 57.1% (n = 425) of respondents (n = 745) indicated that they had been asked for information about PAS by patients. Information about palliative (92.7%; n = 651) and psychological care options (85.6%; n = 598) was deemed most important in cases of requests for PAS. More than half of the respondents (57.6%; n = 429) were in favour of a formal expert assessment of decisional capacity and about 33.4% (n = 249) favoured a time span of 14 days between the counselling and prescription of a lethal drug. There was no association between participants who received more requests and a preference for disclosing publicly their willingness to assist with suicide. A majority of respondents requested measures of quality assurance (71.3%; n = 531).

CONCLUSION

According to respondents' views, the regulation of PAS will require diligent procedures regarding the assessment of decisional capacity and counselling. The findings suggest that the development of adequate and feasible criteria to assess the quality of practices is an important task.

How Do Corporate Social Responsibility Engagements Drive Consumer–Company Identification in Singapore?

Companies expend significant financial resources on corporate social responsibility (CSR) activities to enhance their image. This study had two objectives. By drawing on three fundamental consumer values as moderators, the first aim was to discover how a company’s CSR engagement influences consumer–company identification (CCI) and consumers’ purchase intention for its products and services. The second was to uncover the type of consumer likely to identify with a company engaging in CSR activities. This study presents an exploratory analysis of social media postings by eight companies. An empirical study is conducted using partial least squares structural equation modelling (PLS-SEM) based on survey data from 217 questionnaires collected in Singapore. This study is one of the first to consider what type of consumer would likely identify with a company performing CSR activities. Results show that local-community-focused CSR tends to influence the CCI of egoistic consumers, while environment-focused CSR activities, such as the creation of environmentally-friendly products, drive biospheric consumers’ identification. Broader humanity-focused CSR, such as fair-trade initiatives, significantly influences the CCI of egoistic consumers, but not of altruistic consumers. These findings demonstrate to other economies the significance of local and global companies’ CSR practices and how such activities should be aligned to the CCI of their customer base unique to the region.

A novel methodology to identify and survey physicians participating in medical aid-in-dying

Physicians who participate in medical-aid-in-dying (MAID) cannot be easily identified and studied due to cost and anonymity barriers. We developed and empirically tested a novel methodology to identify and survey physicians highly likely to participate in MAID activities. We used a state-level comprehensive administrative claims database to identify a cohort of patients with diagnoses and hospice enrollment similar to those known to have filled a prescription for MAID from 2017-2018. We then identified physicians who provided routine outpatient care to these patients using National Provider Identifier numbers. We surveyed these physicians in 3 waves (n = 583 total surveys), ranking physicians in order of their likelihood of being asked about MAID for each wave based on characteristics including specialty and the number of unique patients they had provided care to. We re-ranked physicians in waves 2 and 3 based on responses from prior waves. Physicians were surveyed only once and there was no follow-up to preserve anonymity. Surveys assessed the proportion of respondents who participated in MAID activities (discussions, referrals, and/or prescriptions). We identified 6369 physicians that provided care to 2960 patients. In survey waves one, two, and three respectively, response rates (55%, 52%, and 55%; p = 0.98) and the proportion of respondents that participated in MAID activities (58%, 56%, and 42%; p = 0.05) were similar. Small adjustments made to physician ranking criteria in waves two and three did not increase the proportion of physicians that participated in MAID activities. We used a novel methodology using administrative data to identify and survey physicians at high likelihood of participating in MAID activities. We achieved good overall response rates (52%), and a high proportion of respondents that participated in MAID activities (52%), demonstrating that it is possible to overcome cost and anonymity barriers to conducting quantitative research on MAID. This methodology could be used in larger scale studies of MAID or other bioethical issues with "hidden" physician populations.

Factors that Influence End-Of-Life Decision Making Amongst Attending Physicians

Background: Medical advances prolong life and treat illness but many patients have chronically debilitating conditions that prevent them from making end-of-life (EOL) decisions for themselves. These situations are difficult to navigate for both patient and physician. This study investigates physicians' feelings and approach toward EOL care, physician-assisted suicide (PAS), and euthanasia. Methods: An anonymous, self-administered online survey was distributed through the New Jersey Medical School servers and American College of Surgeons forums. The survey presented clinical EOL vignettes and subjective questions regarding PAS and euthanasia. Results: We obtained 142 responses from attending physicians. Respondents were typically male (61%), married (85%), identified as Christian (54%), had more than 20 years of experience (55%), and worked at a university hospital (57%). Religious beliefs and years of work experience seemed to be significant contributors in EOL decision making, whereas gender and medical specialty were not significantly influential. Conclusion: Factors such as years of work experience and religious belief may influence medical professionals' opinions about PAS and euthanasia and their subsequent actions regarding EOL care. In many cases, the boundaries are blurred and require further study before concrete conclusions can be made.

Attitudes on euthanasia among medical students and doctors in Sri Lanka: a cross sectional study

Background

Euthanasia is a topic of intense ethical debate and it is illegal in most countries at present, including Sri Lanka. The aim of this descriptive cross-sectional study of medical students and practicing doctors was to explore the acceptance of euthanasia and physician assisted suicide (PAS), and factors influencing this opinion.

Methods

A customised online questionnaire which explored opinions on euthanasia was administered to first and final year medical undergraduates in University of Colombo and practicing doctors with more than 5 years of work experience at The National Hospital of Sri Lanka. Attitudes on euthanasia and PAS were also assessed with the attitudes towards euthanasia (ATE) Scale, which is a 10-item questionnaire.

Results

A total of 425 individuals responded (males: 178, 42%, age: median – 27 years), which included 143 (33.6%) first-year medical undergraduates, 141 (33.2%) final-year medical undergraduates and 141 (33.2%) practicing doctors. More participants (200, 47.1%) favoured legalizing euthanasia than those directly opposing it (110, 25.9%), but a significant proportion (27%) remained undecided. The mean scores of ATE questionnaire from the whole sample were generally unfavourable towards euthanasia/PAS. Accepting euthanasia as an option for oneself (p =  < 0.001) was the strongest predictor of favouring euthanasia/PAS or supporting its legalization.

Conclusion

In this cross-sectional survey, more respondents supported legalisation of euthanasia in Sri Lanka than those openly opposing it. Yet, a significant minority that responded as “undecided” for legalisation, were more likely to have unfavourable ATE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00731-2.

Physician-Patient Relationship, Assisted Suicide and the Italian Constitutional Court

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.

Meaning and purpose in Huntington's disease: a longitudinal study of its impact on quality of life

Objective

Previous work in Huntington’s disease (HD) has shown that a sense of meaning and purpose (M&P) is positively associated with positive affect and well‐being (PAW); however, it was unknown whether HD‐validated patient‐reported outcomes (PROs) influence this association and how M&P impacts PROs in the future. Our study was designed to examine if HD‐validated PROs moderate the relationship between M&P and PAW and to evaluate if baseline M&P predicts 12‐ and 24‐month changes in HD‐validated PROs.

Methods

This was a longitudinal, multicenter study to develop several PROs (e.g., specific for the physical, emotional, cognitive, and social domains) for people with HD (HDQLIFE). The sample consisted of 322 people with HD (n = 50 prodromal, n = 171 early‐stage manifest, and n = 101 late‐stage manifest HD). A single, multivariate linear mixed‐effects model was performed with PAW as the outcome predicted by main effects for M&P and several moderators (i.e., an HD‐validated PRO) and interactions between M&P and a given PRO. Linear‐mixed models were also used to assess if baseline M&P predicted HD‐validated PROs at 12 and 24 months.

Results

Higher M&P was positively associated with higher PAW regardless of the magnitude of symptom burden, as represented by HD‐validated PROs, and independent of disease stage. In our primary analysis, baseline M&P predicted increased PAW and decreased depression, anxiety, anger, emotional/behavioral disruptions, and cognitive decline at 12 and 24 months across all disease stages.

Interpretation

These findings parallel those seen in the oncology population and have implications for adapting and developing psychotherapeutic and palliative HD interventions.

Facing Death: Attitudes toward Physician-Assisted End of Life among Physicians Working at a Tertiary-Care-Hospital in Israel

The demand for medical assistance in dying remains high and controversial with a large knowledge gap to support optimal patient care. The study aimed to explore physicians’ attitudes regarding euthanasia and examine the factors that related to these attitudes. We surveyed 135 physicians working at a tertiary-care hospital in Israel. The questionnaire was comprised of demographic and background information, DNR procedure information, encounters with terminally ill patients, familiarity with the law regarding end-of-life questions, and Attitudes toward Euthanasia. About 61% agreed that a person has the right to decide whether to expedite their own death, 54% agreed that euthanasia should be allowed, while 29% thought that physicians should preserve a patients’ life even when they expressed the wish to die. A negative statistically significant relationship was found between the level of religiosity and attitudes toward euthanasia. The physicians’ attitudes towards euthanasia are quite positive when compared to other countries. The data shows a conflict of values: the sacredness of human life versus the desire to alleviate patients’ suffering. The Coronavirus-19 outbreak reinforces the importance of supporting physicians’ efforts to provide ethical and empathic communication for terminally ill patients. Future studies should aim to improve our understanding and treatment of the specific types of suffering that lead to end-of-life requests.

[Practice of euthanasia among physicians and nurses in German hospitals]

Hintergrund  Aktive Sterbehilfe und ärztlich assistierter Suizid werden in Deutschland kontrovers diskutiert. Empirische Studien fehlen, um ihr jeweiliges Vorkommen, einschließlich dem von passiver und indirekter Sterbehilfe, in deutschen Krankenhäusern einschätzen zu können. Ärztinnen und Ärzte sowie Pflegerinnen und Pfleger in deutschen Krankhäusern wurden zu ihrer Anwendung von Sterbehilfe befragt und mögliche Einflussfaktoren erhoben.

Methode  Angaben zu Sterbehilfe wurden mit deskriptiven Begriffen und zugeordneten Definitionen in einer anonymen Online-Befragung erhoben. Die objektive und subjektive Arbeitssituation der Befragten und ihre Befürwortung von aktiver Sterbehilfe wurden erfasst. Die finale ärztliche Stichprobe umfasste n = 2507, die pflegerische Stichprobe umfasste n = 2683 Personen.

Ergebnis  Die Anwendung von passiver und indirekter Sterbehilfe innerhalb von 24 Monaten wurde von einem großen Anteil der ärztlichen und pflegerischen Befragten angegeben, aktive Sterbehilfe und assistierter Suizid von deutlich weniger Befragten. Die Varianz in der Anwendung von aktiver Sterbehilfe wurde u. a. durch mehrere arbeitsbezogene Faktoren und die jeweilige Befürwortung von aktiver Sterbehilfe beeinflusst, nicht aber durch subjektive Belastungsfaktoren.

Schlussfolgerung  Sterbehilfe wird durch ärztliche und pflegerische Mitarbeiterinnen und Mitarbeiter in deutschen Krankenhäusern praktiziert. Das Vorkommen unterschiedlicher Formen von Sterbehilfe und relevante Einflussfaktoren werden vor dem Hintergrund methodischer Limitationen diskutiert.

Poststroke suicide risk among older adults in South Korea: A retrospective longitudinal cohort study

OBJECTIVES

The present study evaluated suicide risk within 1 year after discharge among older adults with stroke as a function of depression onset.

METHOD

We used the Korean National Health Insurance Service-Senior cohort data and included first discharged patients with a stroke as the principal diagnosis. The comparison group was selected by a 1:2 case-control propensity score matching for age, sex, Charlson comorbidity index, and diagnosis year between 2005 and 2012. Suicide deaths were measured by code for causes of death from Statistics Korea, and the main outcome was suicide death within 1 year following discharge. An adjusted hazard ratio (AHR) of suicidal risk was measured using a Cox proportional hazard model.

RESULTS

In the total sample of 128 286 older adults (aged 63-114 years), the higher suicidal risk was examined for stroke patients vs the comparison group (AHR = 1.4; 95% confidence interval [CI], 1.1-1.8). Stroke patients with depression had an increased suicide risk (AHR = 2.9; 95% CI, 1.8-4.8) but only for poststroke depression (AHR = 4.1; 95% CI, 1.8-9.5). Pre and poststroke depression suicidality (AHR = 4.8; 95% CI, 2.1-11.1) was also higher when compared to stroke patients without depression.

CONCLUSIONS

Poststroke patients are at increased suicidal risk during 1 year following discharge. Furthermore, patients who were diagnosed with depression after a stroke are more likely to commit suicide than stroke patients without depression. This suggests a necessity for early suicide preventive intervention for stroke patients while considering depressive symptomology.

French Physicians’ Attitudes toward Legalisation of Euthanasia and the Ambiguous Relationship between Euthanasia and Palliative Care

In 1999, the French Parliament established a “right to palliative care”, which reactivated public debate about euthanasia. In order to investigate jointly physicians’ attitude toward palliative care and euthanasia, we conducted a cross-sectional survey of a national sample of French GPs, oncologists, and neurologists. Overall, 917 physicians participated in the survey. Significant proportions of respondents, especially among GPs and neurologists, considered that palliative sedation and withdrawing life-sustaining treatments (WLST) were euthanasia. Multivariate analysis showed that the physicians who had special medical training in palliative care, and those who distinguish palliative sedation and WLST from euthanasia were more likely to oppose legalisation of euthanasia. Thus, French physicians’ attitude to the legalisation of euthanasia is strongly influenced by whether or not they distinguish palliative care from euthanasia. Improved palliative care requires better training of the entire medical profession, and clearer guidelines about which end-of-life care practices are legally and ethically acceptable.

Comparison of attitudes towards five end-of-life care interventions (active pain control, withdrawal of futile life-sustaining treatment, passive euthanasia, active euthanasia and physician-assisted suicide): a multicentred cross-sectional survey of Korean patients with cancer, their family caregivers, physicians and the general Korean population

OBJECTIVES

This study determined attitudes of four groups-Korean patients with cancer, their family caregivers, physicians and the general Korean population-towards five critical end-of-life (EOL) interventions-active pain control, withdrawal of futile life-sustaining treatment (LST), passive euthanasia, active euthanasia and physician-assisted suicide.

DESIGN AND SETTING

We enrolled 1001 patients with cancer and 1006 caregivers from 12 large hospitals in Korea, 1241 members of the general population and 928 physicians from each of the 12 hospitals and the Korean Medical Association. We analysed the associations of demographic factors, attitudes towards death and the important components of a 'good death' with critical interventions at EoL care.

RESULTS

All participant groups strongly favoured active pain control and withdrawal of futile LST but differed in attitudes towards the other four EoL interventions. Physicians (98.9%) favoured passive euthanasia more than the other three groups. Lower proportions of the four groups favoured active euthanasia or PAS. Multiple logistic regression showed that education (adjusted OR (aOR) 1.77, 95% CI 1.33 to 2.36), caregiver role (aOR 1.67, 95% CI 1.34 to 2.08) and considering death as the ending of life (aOR 1.66, 95% CI 1.05 to 1.61) were associated with preference for active pain control. Attitudes towards death, including belief in being remembered (aOR 2.03, 95% CI 1.48 to 2.79) and feeling 'life was meaningful' (aOR 2.56, 95% CI 1.58 to 4.15) were both strong correlates of withdrawal of LST with the level of monthly income (aOR 2.56, 95% CI 1.58 to 4.15). Believing 'freedom from pain' negatively predicted preference for passive euthanasia (aOR 0.69, 95% CI 0.55 to 0.85). In addition, 'not being a burden to the family' was positively related to preferences for active euthanasia (aOR 1.62, 95% CI 1.39 to 1.90) and PAS (aOR 1.61, 95% CI 1.37 to 1.89).

CONCLUSION

Groups differed in their attitudes towards the five EoL interventions, and those attitudes were significantly associated with various attitudes towards death.

How Should Physicians Care for Dying Patients with Amyotrophic Lateral Sclerosis?

We discuss physician aid in dying, euthanasia, and other dimensions of palliative care decision making and define relevant terms raised by this case of a dying patient with amyotrophic lateral sclerosis in Washington State who is unable to self-administer a lethal prescription. We then present a concrete framework that clinicians can directly apply when faced with difficult cases such as this one. We outline how exploring motivations, obtaining informed consent, defining goals, and examining alternatives can help guide physicians like the one in this case. We conclude by summarizing one way in which physicians might balance these issues while still remaining within the constraints of the law.

Medical assistance in dying: Examining Canadian pharmacy perspectives using a mixed-methods approach

Background:

Canada legalized assisted dying with the passing of Bill C-14, Medical Assistance in Dying (MAiD), in June 2016. This legislation has implications for health care professionals participating in MAiD. This research aims to understand the effect that MAiD has on pharmacists and pharmacy technicians in Canada.

Methods:

We conducted a thematic document analysis of pharmacy guidelines, position statements and standards of practice from pharmacy regulatory authorities across Canada. In addition, the Ontario Pharmacists Association surveyed its members (including pharmacists, pharmacy technicians and pharmacy students) about their perceptions of MAiD.

Results:

Our thematic analysis of the reviewed documents resulted in 3 major themes: pharmacists’ role in quality assurance, practice considerations when implementing MAiD and resources for pharmacy staff involved in MAiD. Survey responses illustrated that most (68%) pharmacy staff would dispense MAiD medications. Nonetheless, many respondents perceived that they lacked knowledge or comfort with different aspects of the MAiD process. Overall, 80% of participants reported a desire for professional development about MAiD.

Conclusion:

Despite the rapidly changing landscape surrounding medical assistance in dying within the past year, most pharmacy regulatory authorities have provided direction and resources to their pharmacists. Ontario pharmacists and pharmacy technicians are willing to dispense MAiD medications; however, additional support in the form of professional development may be necessary based on participants’ desire for education coupled with their perceived lack of knowledge. Future research may focus on the efficacy of provincial guidelines in supporting pharmacists’ participation in MAiD.

National Survey of Medical Choices in Caring for Terminally ill Patients in Italy, a Cross-Sectional Study

Aims and background

In Italy, euthanasia and assisted suicide remain illegal but have been the subject of constant debate. Such discussions, however, seem to take relatively little account of physicians' views and attitudes.

Methods and study design

We used an anonymous questionnaire to survey the attitudes and practices concerning euthanasia and the care of terminally ill patients of 5000 Italian physicians from among the approximately 20,000 members of seven of the most important Italian scientific societies. They were asked to complete an anonymous questionnaire consisting of 15 items, which also collected demographic and professional information.

Results

The response rate was 23.5%, and 855 questionnaires were returned. The respondents (75% males) had a median age of 51 years and 47% practiced medicine in a hospital or university setting. The survey showed that the attitude of Italian physicians towards caring for terminal patients is generally against the practice of euthanasia insofar as 84% and 87%, respectively, would, on a theoretical basis, be unwilling to prescribe or administer lethal drugs. Only 1.2-2% of the physicians declared that they had resorted at least once to active euthanasia practices consisting of the prescription and/or direct administration of lethal drugs during their professional lives, and 0.5–0.9% during the previous year. The main factor significantly influencing the opinions and behaviors of the physicians was religion.

Conclusions

To our knowledge, this is the first Italian survey investigating the opinions and practices on euthanasia of a large sample of physicians from all over the country, belonging to various medical specialties. Our findings confirm the considerable influence of religion on physician's opinions and practice concerning end-of-life care.

Risk of Suicide Attempt in Poststroke Patients: A Population-Based Cohort Study

BACKGROUND

This nationwide population-based cohort study evaluated the risk of and risk factors for suicide attempt in poststroke patients in Taiwan.

METHODS AND RESULTS

The poststroke and nonstroke cohorts consisted of 713 690 patients and 1 426 009 controls, respectively. Adults (aged >18 years) who received new stroke diagnoses according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM; codes 430-438) between 2000 and 2011 were included in the poststroke cohort. We calculated the adjusted hazard ratio for suicide attempt (ICD-9-CM codes E950-E959) after adjustment for age, sex, monthly income, urbanization level, occupation category, and various comorbidities. Kaplan-Meier analysis was used to measure the cumulative incidence of suicide attempt, and the Fine and Gray method was used as a competing event when estimating death subhazard ratios and 95% confidence intervals between groups. The cumulative incidence of suicide attempt was higher in the poststroke cohort, and the adjusted hazard ratio of suicide attempt was 2.20 (95% confidence interval, 2.04-2.37) compared with that of the controls. The leading risk factors for poststroke suicide attempt were earning low monthly income (<660 US dollars), living in less urbanized regions, doing manual labor, and having a stroke before age 50 years. The attempted suicide risk did not differ significantly between male and female patients in this study.

CONCLUSIONS

These results convey crucial information to clinicians and governments for preventing suicide attempt in poststroke patients in Taiwan and other Asian countries.

Meaning in Life as a Mediator Between Physical Impairment and the Wish to Hasten Death in Patients With Advanced Cancer

CONTEXT

Meaning in life (MiL) is a key factor for ensuring spiritual well-being and quality of life among patients with life-threatening illnesses. However, the role of MiL in relation to the wish to hasten death (WTHD) and its interaction with other physical and psychological factors in patients with advanced cancer has not yet been studied.

OBJECTIVE

The objective of this study was to analyze the relationship between the WTHD and MiL and to propose a theoretical model of functional relationships among WTHD, performance status, depression, and MiL.

METHODS

This is a cross-sectional study of 101 patients in a palliative care unit, who were assessed in the context of a clinical interview. Outcome measures included performance status, depression, MiL, and the WTHD. Structural equation modeling was used to analyze the functional relationships between these factors.

RESULTS

The WTHD correlated significantly (P < 0.01) with MiL (r = 0.60), performance status (r = 0.548), and depression (r = 0.397). The structural equation modeling analysis showed that although there was no significant direct effect between performance status and the WTHD, there was a significant total effect because of the mediation of depression and MiL. The latter played the most significant role, accounting for 76.5% of the mediation.

CONCLUSION

These results support the proposed model and provide evidence of a mediator effect of MiL and depression on the relationship between physical impairment and the WTHD in advanced patients. Our findings suggest that interventions to enhance MiL could help to address and/or prevent the emergence of a WTHD in this population.

Suffering and dying well: on the proper aim of palliative care

In recent years a large empirical literature has appeared on suffering at the end of life. In this literature it is recognized that suffering has existential and social dimensions in addition to physical and psychological ones. The non-physical aspects of suffering, however, are still understood as pathological symptoms, to be reduced by therapeutical interventions as much as possible. But suffering itself and the negative emotional states it consists of are intentional states of mind which, as such, make cognitive claims: they are more or less appropriate responses to the actual circumstances of the patient. These circumstances often are such that it would rather be a pathological symptom not to be sad and not to suffer. Suffering, therefore, is sometimes and to some extent a condition to be respected. Although I do not dispute that the alleviation of suffering is the main aim of palliative care, in pursuing that aim we should acknowledge a constraint of realism.

"We need to talk!" Barriers to GPs' communication about the option of physician-assisted suicide and their ethical implications: results from a qualitative study

GPs usually care for their patients for an extended period of time, therefore, requests to not only discontinue a patient's treatment but to assist a patient in a suicide are likely to create intensely stressful situations for physicians. However, in order to ensure the best patient care possible, the competent communication about the option of physician assisted suicide (PAS) as well as the assessment of the origin and sincerity of the request are very important. This is especially true, since patients' requests for PAS can also be an indicator for unmet needs or concerns. Twenty-three qualitative semi-structured interviews were conducted to in-depth explore this multifaceted, complex topic while enabling GPs to express possible difficulties when being asked for assistance. The analysis of the gathered data shows three main themes why GPs may find it difficult to professionally communicate about PAS: concerns for their own psychological well-being, conflicting personal values or their understanding of their professional role. In the discussion part of this paper we re-assess these different themes in order to ethically discuss and analyse how potential barriers to professional communication concerning PAS could be overcome.

The Attitudes of Greek Physicians and Lay People on Euthanasia and Physician-Assisted Suicide in Terminally Ill Cancer Patients

The purpose of this article is to explore the attitudes of lay people and physicians regarding euthanasia and physician-assisted suicide in terminally ill cancer patients in Greece. The sample consisted of 141 physicians and 173 lay people. A survey questionnaire was used concerning issues such as euthanasia, physician-assisted suicide, and so forth. Many physicians (42.6%) and lay people (25.4%, P = .002) reported that in the case of a cardiac and/or respiratory arrest, there would not be an effort to revive a terminally ill cancer patient. Only 8.1% of lay people and 2.1% of physicians agreed on physician-assisted suicide ( P = .023). Many of the respondents, especially physicians, supported sedation but not euthanasia or physician-assisted suicide. However, many of the respondents would prefer the legalization of a terminally ill patient's hastened death.

Euthanasia and the Administration of Neuromuscular Blockers without Ventilation: Should Physicians Fear Prosecution?

A common dilemma among physicians who treat the dying is whether pharmacological paralysis should be reversed prior to removal of mechanical ventilation. But what if a physician were to administer a neuromuscular blocker without ever ventilating the patient in the first place? While there is evidence that euthanasia does occur in the United States, few physicians have been prosecuted. Could these infrequent prosecutions reflect a conscious desire by prosecutors not to pursue such matters? In an effort to explore this question, chief prosecutors in four U.S. states were presented with a vignette based on an actual event involving the administration of Succinylcholine to a dying patient. Response rates in this study were very acceptable (76.36% overall), and results indicated that not only was the likelihood of criminal prosecution low, almost half of the prosecutors believed that a physicianadministered lethal injection may be morally justified in some circumstances even though illegal.

Attitudes, Sociodemographic Characteristics, and Actual End-of-Life Decisions of Physicians in Flanders, Belgium

Aim. To study the effect of sociodemographic and attitudinal determinants of physicians making end-of-life decisions (ELDs). Methods. The physicians having signed 489 consecutive death certificates in the city of Hasselt (Belgium) were sent an anonymous questionnaire regarding their ELDs and another on their attitudes toward voluntary euthanasia (EUTH) and physician-assisted suicide (PAS).Results.55% response rate. Nontreatment decisions occurred in 16.7% of all death cases; in 16%, there was potentially life-shortening use of drugs to alleviate pain and symptoms; in 4.8% of cases,death was deliberately induced by lethal drugs, including EUTH, PAS, and life termination without explicit request by the patient. In their attitudes toward EUTH and PAS, the 92 responding physicians clustered into 3 groups: positive and rule oriented, positive rule-adverse, and opposed. Cluster groupmembership, commitment to life stance, years of professional experience, and gender were each associated with specific ELD-making patterns.

Medical end-of-life practices among Canadian physicians: a pilot study

BACKGROUND

Medical end-of-life practices are hotly debated in Canada, and data from other countries are used to support arguments. The objective of this pilot study was twofold: to adapt and validate a questionnaire designed to measure the prevalence of these practices in Canada and the underlying decision-making process, and to assess the feasibility of a nationally representative study.

METHODS

In phase 1, questionnaires from previous studies were adapted to the Canadian context through consultations with a multidisciplinary committee and based on a scoping review. The modified questionnaire was validated through cognitive interviews with 14 physicians from medical specialties associated with a higher probability of being involved with dying patients recruited by means of snowball sampling. In phase 2, we selected a stratified random sample of 300 Canadian physicians in active practice from a national medical directory and used the modified tailored method design for mail and Web surveys. There were 4 criteria for success: modified questions are clearly understood; response patterns for sensitive questions are similar to those for other questions; respondents are comparable to the overall sampling frame; and mean questionnaire completion time is less than 20 minutes.

RESULTS

Phase 1: main modifications to the questionnaire were related to documentation of all other medical practices (including practices intended to prolong life) and a question on the proportionality of drugs used. The final questionnaire contained 45 questions in a booklet style. Phase 2: of the 280 physicians with valid addresses, 87 (31.1%) returned the questionnaire; 11 of the 87 declined to participate, for a response rate of 27.1% (n = 76). Most respondents (64 [84%]) completed the mail questionnaire. All the criteria for success were met.

INTERPRETATION

It is feasible to study medical end-of-life practices, even for practices that are currently illegal, including the intentional use of lethal drugs. Results from this pilot study support conducting a large national study, but additional strategies would be necessary to improve the response rate.

Individual meaning in life assessed with the Schedule for Meaning in Life Evaluation: toward a circumplex meaning model

OBJECTIVE

The experience of "meaning in life" (MiL) is a major aspect of life satisfaction and psychological well-being. To assess this highly individual construct, idiographic measures with open-response formats have been developed. However, it can be challenging to categorize these individual experiences for interindividual comparisons. Our study aimed to derive MiL categories from individual listings and develop an integrative MiL model.

METHOD

University students were asked to rate 58 MiL providing aspects recently found in a nationwide study using the Schedule for Meaning in Life Evaluation (SMiLE), an MiL instrument allowing for open responses. Pearson's correlations and factor analyses were used to test the unidimensionality of subsequently derived higher-order MiL categories. Multidimensional scaling, cluster analysis, and factor analysis were performed to further analyze a latent MiL structure.

RESULTS

A total of 340 students participated in the study. Some 11 unidimensional categories consisting of 34 meaning-providing aspects were summarized into a circumplex model with four MiL domains: leisure/health, work/finances, culture/spirituality, and relationships (family, partnership, social relations).

SIGNIFICANCE OF RESULTS

This model seems to incorporate a major portion of individual respondent-generated MiL listings. It may be useful for future idiographic MiL studies to help organize individual experiences of MiL and allow for higher-level interindividual comparisons. Further studies including different samples are necessary to confirm this model or derive other MiL domains, for example, in palliative care patients or patients who are confronted with a loss of meaning.

Suicide in later life: failed treatment or rational choice?

Suicide is the deliberate act of causing death by self-directed injurious behavior with intent to die. Assisted dying, also known as assisted suicide, involves others to help hasten death. Physician-assisted dying specifically refers to the participation of a physician in facilitating one's death by providing a lethal means. Any decision to actively end a life has profound emotional and psychological effects on survivors. The article discusses the effects that older adults' deaths through suicide, assisted dying, and physician-assisted dying have on survivors and the implications for clinical practice.

Israeli Dying Patient Act: physician knowledge and attitudes

OBJECTIVES

The recently enacted Israeli Dying Patient Act was designed to strike balance between enhancing patient autonomy in end-of-life decision making and cultural/religious norms that are in opposition to active euthanasia and physician-assisted suicide (PAS). The current study evaluated physician attitudes regarding active and passive euthanasia, and their knowledge of specific aspects of the law.

METHODS

A survey was administered to a convenience sample of hospital-based physicians treating terminal patients. Physicians were queried about their attitudes regarding euthanasia and PAS. Physicians were also queried about specific aspects of the law and whether they had sufficient resources to uphold the law.

RESULTS

Surveys were distributed to 270 physicians and 100 were returned and evaluated (37%). Nearly all physicians supported passive euthanasia (withholding treatment), whereas over 40% maintained that active forms of euthanasia should be allowed for terminal patients in severe physical pain. Multivariate analysis showed a negative relationship between support for more active forms of euthanasia and physicians' self-reported religiosity. Physicians cited lack of time as a reason for not complying with the new law. Physicians had a familiarity with the general aspects of the new legislation, but a large proportion was not aware of the specifics of the law.

CONCLUSIONS

Compared with previous surveys, a larger number of physicians support passive euthanasia. A sizable percentage of physicians would be willing to participate in active euthanasia and even PAS. Attitudes toward euthanasia are influenced by religious factors.

Comparing end-of-life practices in different policy contexts: a scoping review

Objectives

End-of-life policy reforms are being debated in many countries. Research evidence is used to support different assumptions about the effects of public policies on end-of-life practices. It is however unclear whether reliable international practice comparisons can be conducted between different policy contexts. Our aim was to assess the feasibility of comparing similar end-of-life practices in different policy contexts.

Methods

This is a scoping review of empirical studies on medical end-of-life practices. We developed a descriptive classification of end-of-life practices that distinguishes practices according to their legal status. We focused on the intentional use of lethal drugs by physicians because of international variations in the legal status of this practice. Bibliographic database searches were supplemented by expert consultation and hand searching of reference lists. The sensitivity of the search strategy was tested using a set of 77 articles meeting our inclusion criteria. Two researchers extracted end-of-life practice definitions, study methods and available comparisons across policy contexts. Canadian decision-makers were involved to increase the policy relevance of the review.

Results

In sum, 329 empirical studies on the intentional use of lethal drugs by doctors were identified, including studies from 19 countries. The bibliographic search captured 98.7% of studies initially identified as meeting the inclusion criteria. Studies on the intentional use of lethal drugs were conducted in jurisdictions with permissive (62%) and restrictive policies (43%). The most common study objectives related to the frequency of end-of-life practices, determinants of practices, and doctors’ adherence to regulatory standards. Large variations in definitions and research methods were noted across studies. The use of a descriptive classification was useful to translate end-of-life practice definitions across countries. A few studies compared end-of-life practice in countries with different policies, using consistent research methods. We identified no comprehensive review of end-of-life practices across different policy contexts.

Conclusions

It is feasible to compare end-of-life practices in different policy contexts. A systematic review of international evidence is needed to inform public deliberations on end-of-life policies and practice.

[Effects of dignity interventions on psychosocial and existential distress in terminally ill patients: a meta-analysis]

PURPOSE

This study was done to evaluate the effects of dignity interventions on depression, anxiety and meaning of life in terminally ill patients.

METHODS

PubMed, Cochrane Library CENTRAL, EMBASE, CINAHL and several Korean databases were searched. The main search strategy combined terms indicating dignity intervention, presence of terminal illness and study design. Methodological quality was assessed using Cochrane's Risk of Bias for randomized studies and Risk of Bias Assessment tool for non randomized studies. Data were analyzed by the RevMan 5.2.11 program of Cochrane Library.

RESULTS

Twelve clinical trials met the inclusion criteria with a total of 878 participants. Dignity intervention was conducted for a mean of 2.2 weeks, 2.8 sessions and an average of 48.7 minutes per session. Effect sizes were heterogeneous and subgroup analysis was done. Dignity interventions had a significant effect on depression (ES=-1.05, p<.001, I²=15%) and anxiety (ES=-1.01, p<.001, I²=0). For meaning of life, dignity interventions were effective (ES=-1.64, p=.005) and effect sizes were still heterogeneous.

CONCLUSION

Results support findings that dignity interventions can assist terminal ill patients in reducing emotional distress and improving meaning of life. Further well-designed dignity studies will lead to better understanding of the effects of treatments on spiritual well-being.

Does desire for hastened death change in terminally ill cancer patients?

Understanding why some terminally ill patients may seek a hastened death (a construct referred to as "desire for hastened death" or DHD) is critical to understanding how to optimize quality of life during an individual's final weeks, months or even years of life. Although a number of predictor variables have emerged in past DHD research, there is a dearth of longitudinal research on how DHD changes over time and what factors might explain such changes. This study examined DHD over time in a sample of terminally ill cancer patients admitted to a palliative care hospital. A random sample of 128 patients completed the Schedule of Attitudes toward Hastened Death (SAHD) at two time points approximately 2-4 weeks apart participated. Patients were categorized into one of four trajectories based on their SAHD scores at both time points: low (low DHD at T1 and T2), rising (low DHD at T1 and high DHD at T2), falling (high DHD at T1 and low DHD at T2) and high (high DHD at T1 and T2). Among patients who were low at T1, several variables distinguished between those who developed DHD and those who did not: physical symptom distress, depression symptom severity, hopelessness, spiritual well-being, baseline DHD, and a history of mental health treatment. However, these same medical and clinical variables did not distinguish between the falling and high trajectories. Overall, there appears to be a relatively high frequency of change in DHD, even in the last weeks of life. Interventions designed to target patients who are exhibiting subthreshold DHD and feelings of hopelessness may reduce the occurrence of DHD emerging in this population.

Bridging the Gap Between Continuous Sedation Until Death and Physician-Assisted Death

The distinction between continuous sedation until death (CSD) and physician-assisted death (PAD) has become a topic of medical ethical debate. We conducted 6 focus groups to examine how nursing home clinicians perceive this distinction. For some, the difference is clear whereas others consider CSD a form of euthanasia. Another group situates CSD between pain relief and ending life. Arguments for these perspectives refer to the following themes: intention, dosage of sedative drugs, unconsciousness, and the pace of the dying process. Generally, CSD is considered emotionally easier to deal with since it entails a gradual dying process. Nursing home clinicians have diverging perceptions of the relation between CSD and PAD; some consider CSD to be more than a purely palliative measure, that is, also as a means to hasten death.

Physician aid-in-dying: cautionary words

PURPOSE OF REVIEW

Physician-assisted suicide (PAS) and euthanasia have been increasingly discussed in end-of-life care, as PAS and euthanasia have now been legalized in three European countries and PAS has been legalized in Washington, Oregon, and Montana in the USA. This review focuses on some aspects of PAS and euthanasia and discusses deep terminal sedation (DTS), which is increasingly used to treat intractable symptoms at the end of life.

RECENT FINDINGS

PAS and euthanasia present potential risks for vulnerable populations, such as the depressed and disabled. The Oregon experience does not allow specific analysis regarding disabled patients, but fewer psychiatric consultations are being done to evaluate patients for depression. In the Netherlands, a small number of patients undergo euthanasia without an explicit request. Twenty percent of cases go unreported, raising questions of whether they met legal standards. The use of DTS in all countries has increased, but in a significant number of cases, DTS is used with an explicit intent to hasten death. Double-effect arguments to justify DTS may not actually apply.

SUMMARY

Caution is warranted regarding PAS and euthanasia, as vulnerable patients may still be at risk. More research is needed to characterize the use (and misuse) of DTS.

Is educational attainment related to end-of-life decision-making? A large post-mortem survey in Belgium

BACKGROUND

Educational attainment has been shown to influence access to and quality of health care. However, the influence of educational attainment on decision-making at the end of life with possible or certain life-shortening effect (ELDs ie intensified pain and symptom alleviation, non-treatment decisions, euthanasia/physician-assisted suicide, and life-ending acts without explicit request) is scarcely studied. This paper examines differences between educational groups pertaining to prevalence of ELDs, the decision-making process and end-of-life treatment characteristics.

METHOD

We performed a retrospective survey among physicians certifying a large representative sample of Belgian deaths in 2007. Differences between educational groups were adjusted for relevant confounders (age, sex, cause of death and marital status).

RESULTS

Intensified pain and symptom alleviation and non-treatment decisions are more likely to occur in higher educated than in lower educated patients. These decisions were less likely to be discussed with either patient or family, or with colleague physicians, in lower educated patients. A positive association between education and prevalence of euthanasia/assisted suicide (acts as well as requests) disappeared when adjusting for cause of death. No differences between educational groups were found in the treatment goal in the last week, but higher educated patients were more likely to receive opioids in the last day of life.

CONCLUSION

There are some important differences and possible inequities between educational groups in end-of-life decision-making in Belgium. Future research should investigate whether the found differences reflect differences in knowledge of and adherence to patient preferences, and indicate a discrepancy in quality of the end of life.

Discussing physician-assisted dying: physicians' experiences in the United States and the Netherlands

PURPOSE OF THE STUDY

This study aims to further our understanding of the experiences of physicians when discussing physician-assisted dying (PAD) within the context of doctor-patient relationships in various sociolegal settings. Although patients bring up PAD in diverse settings, little is known about how physicians experience these discussions, and such experiences have not been directly compared across countries.

DESIGN AND METHODS

A total of 36 physicians in the Netherlands and the United States (including Oregon) were interviewed using individual semistructured interview guides. Interviews were conducted by a single interviewer, audiotaped, and independently transcribed. Inductive qualitative analysis, aided by NVivo7 software, directed purposive sampling of physicians until saturation was met. Multiple coders in a multidisciplinary team analyzed emerging themes and developed theory.

RESULTS

PAD discussions, which ranged from theoretical discussions to actual requests, could be gateways to discussions of other end-of-life issues important to patients and could strengthen doctor-patient relationships. Physicians found discussions to be emotionally intense, but often rewarding. Where PAD was legal, physicians utilized existing criteria to guide communication, and discussions were open and honest with patients and colleagues. Where PAD was illegal, conversations were less explicit, and physicians dealt with requests in relative isolation. In addition, physicians' views of their professional role, patients' rights, and religion influenced both their willingness to have and the content of PAD discussions.

IMPLICATIONS

Discussion of PAD is an energy-consuming, yet potentially enriching part of the doctor-patient relationship. Legal guidelines may help to provide structure and support for physicians when patients broach the topic of PAD.

Intentional sedation to unconsciousness at the end of life: findings from a national physician survey

CONTEXT

The terms "palliative sedation" and "terminal sedation" have been used to refer to both proportionate palliative sedation, in which unconsciousness is a foreseen but unintended side effect, and palliative sedation to unconsciousness, in which physicians aim to make their patients unconscious until death. It has not been clear to what extent palliative sedation to unconsciousness is accepted and practiced by U.S. physicians.

OBJECTIVES

To investigate U.S. physician acceptance and practice of palliative sedation to unconsciousness and to identify predictors of that practice.

METHODS

In 2010, a survey was mailed to 2016 practicing U.S. physicians. Criterion measures included self-reported practice of palliative sedation to unconsciousness until death and physician endorsement of such sedation for a hypothetical patient with existential suffering at the end of life.

RESULTS

Of the 1880 eligible physicians, 1156 responded to the survey (62%). One in ten (141/1156) physicians had sedated a patient in the previous 12 months with the specific intention of making the patient unconscious until death, and two of three physicians opposed sedation to unconsciousness for existential suffering, both in principle (68%, n = 773) and in the case of a hypothetical dying patient (72%, n = 831). Eighty-five percent (n = 973) of physicians agreed that unconsciousness is an acceptable side effect of palliative sedation but should not be directly intended.

CONCLUSION

Although there is widespread support among U.S. physicians for proportionate palliative sedation, intentionally sedating dying patients to unconsciousness until death is neither the norm in clinical practice nor broadly supported for the treatment of primarily existential suffering.

First do no harm: pressing concerns regarding euthanasia in Belgium

This article is concerned with the practice of euthanasia in Belgium. Background information is provided; then major developments that have taken place since the enactment of the Belgian Act on Euthanasia are analysed. Concerns are raised about (1) the changing role of physicians and imposition on nurses to perform euthanasia; (2) the physicians' confusion and lack of understanding of the Act on Euthanasia; (3) inadequate consultation with an independent expert; (4) lack of notification of euthanasia cases, and (5) organ transplantations of euthanized patients. Some suggestions designed to improve the situation and prevent abuse are offered.

Personal dignity in the terminally ill from the perspective of caregivers: a survey among trained volunteers and physicians

BACKGROUND

Although dignity is increasingly considered a goal of palliative care, little research has evaluated the understanding of dignity at the end of life from a caregiver's perspective.

OBJECTIVE

The study objective was to investigate and compare the views of trained volunteers and SCEN physicians on maintaining dignity for patients reaching the end of life.

DESIGN

The study is a survey questionnaire study.

SUBJECTS

Subjects were two groups of caregivers involved in care for dying patients: trained volunteers (n=236) and end-of-life consultants (SCEN physicians; n=427).

MEASUREMENTS

Measurement was done via the Dutch version of the 22-item Patient Dignity Inventory on symptoms and experiences that have been shown to influence the sense of dignity in terminally ill patients. Respondents were asked to rate on a five-point scale the extent to which they considered the items as influential on dignity in terminally ill patients, and as problematic in practice in maintaining dignity for patients in the last phase of life.

RESULTS

Overall, volunteers indicated items more frequently as influential to dignity and as problematic in maintaining dignity at the end of life, compared to SCEN physicians. Volunteers gave significantly higher ratings than SCEN physicians to most of the social items, and to half of the psychological and existential items.

CONCLUSIONS

It seems that SCEN physicians consider the physical aspects of suffering to be most influential and problematic in practice in preserving dignity, while volunteers think psychosocial aspects are most important in preserving dignity at the end of life. These findings suggest that the role and responsibilities of caregivers involved in care for terminally ill patients affect the factors that they think influence dignity.