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Scheeres-Feitsma TM, Schaafsma P, van der Steen JT. A family affair: Repeated interviews with people with dementia and a euthanasia wish and their families. DEATH STUDIES 2024:1-11. [PMID: 39052438 DOI: 10.1080/07481187.2024.2376819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
This study examines the reasons of people with dementia request euthanasia and how these reasons change over time with a special focus on reasons related to family. In addition, it examines how family relates to their loved one's euthanasia wish. Seven people with dementia and a euthanasia wish in the Netherlands were interviewed, and three years later, two of them and five family members were interviewed again. Four themes were identified using thematic analyses: (1) Protecting the relationship from the impact of dementia; (2) Private domain as the primary setting to discuss euthanasia; (3) Implicit expectation to respect and agree with the euthanasia wish; (4) Experienced responsibilities of family regarding the euthanasia wish. Professionals should be aware of the position of family and the interrelatedness of the person's concern for family happiness and families' moral commitment to agree and support the wish.
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Affiliation(s)
- Trijntje M Scheeres-Feitsma
- Protestant Theological University Amsterdam, Amsterdam, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
- Cicely Saunders Institute, King's College London, London, United Kingdom
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Komesaroff PA, Chapman M, Lamba G, Kerridge IH, Stewart CL, Holmes A, Lewis S, Philip J. Should voluntary assisted dying in Victoria be extended to encompass people with dementia? Med J Aust 2024; 220:452-454. [PMID: 38571369 DOI: 10.5694/mja2.52273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/22/2024] [Indexed: 04/05/2024]
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Barć K, Finsel J, Helczyk O, Baader S, Aho‐Özhan H, Ludolph AC, Lulé D, Kuźma‐Kozakiewicz M. One third of physicians discuss exit strategies with patients with amyotrophic lateral sclerosis: Results from nationwide surveys among German and Polish neurologists. Brain Behav 2024; 14:e3243. [PMID: 38183365 PMCID: PMC10897500 DOI: 10.1002/brb3.3243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 01/08/2024] Open
Abstract
OBJECTIVE This paper examines neurologists' approaches to exit strategies (ESs), such as euthanasia and physician-assisted suicide, in patients with amyotrophic lateral sclerosis (PALS) in two European countries. METHODS In a nationwide anonymous survey, we collected responses from 237 Polish and 228 German neurologists, focusing on their practices and beliefs about ESs, as well as their viewpoints on life-sustaining measures (LSMs) (percutaneous endoscopic gastrostomy, non-invasive, and invasive ventilation). To analyze the data, we employed statistical methods, including Mann-Whitney U, Kruskal-Wallis, chi-square tests, Spearman's rank correlation, and multiple regression analysis. RESULTS One third of the neurologists initiated the discussion about ESs with PALS. Half were ready to have this conversation upon patient's request. Age, gender, religiousness, and nationality were closely associated with this approach. One in 9 neurologists received a request to terminate an LSM, whereas 1 in 10 to implement an ES. German neurologists and palliative care trainees acquired both demands more commonly. Neurologists quoted a low quality of life, decreased mood, and being a burden to the family/closest ones as primary reasons for a wish to hasten death among PALS. Although the majority expressed a willingness to terminate an LSM at a request of the patient, most opposed the legalization of euthanasia. Younger and less religious individuals were more likely to favor accepting euthanasia. CONCLUSION Neurologists vary significantly in their approaches to terminal care. Complex relationships exist among personal indices, shared beliefs, and current practices.
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Affiliation(s)
- Krzysztof Barć
- Department of NeurologyUniversity Clinical Centre of Medical University of WarsawWarsawPoland
| | - Julia Finsel
- Department of NeurologyUniversity of UlmUlmGermany
| | - Olga Helczyk
- Department of NeurologyUniversity of UlmUlmGermany
| | | | | | - Albert C. Ludolph
- Department of NeurologyUniversity of UlmUlmGermany
- German Centre of Neurodegenerative Diseases (DZNE)UlmGermany
| | | | - Magdalena Kuźma‐Kozakiewicz
- Department of NeurologyMedical University of WarsawWarsawPoland
- Neurodegenerative Diseases Research GroupMedical University of WarsawWarsawPoland
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van der Steen JT, Scheeres‐Feitsma TM, Schaafsma P. Commentary to: "Timely dying in dementia: Use patients' judgments and broaden the concept of suffering." Timely dying, suffering in dementia, and a role for family and professional caregivers in preventing it. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2024; 16:e12536. [PMID: 38496722 PMCID: PMC10941495 DOI: 10.1002/dad2.12536] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/14/2023] [Indexed: 03/19/2024]
Abstract
Broadening the concept of suffering in dementia to five types of suffering including suffering of family caregivers as proposed by Terman et al., may help raise awareness on a need to relieve suffering when living with dementia and adopt a holistic approach. However, as objective criteria in advance care plans for severe enough suffering to stop assisted feeding or other life-sustaining treatment in people with advanced dementia, these still need interpretation in the context of, for example, available treatment, and change in coping. New is the proposal to broaden severe enough suffering to suffering of family, including "bi-directional empathic suffering." We believe this creates new dilemmas regarding responsibility and may increase feelings of guilt. Quantifying suffering by adding up moderate suffering could further complicate matters. Therefore, we argue that a health care professional should guide the process and assume responsibility over current decisions to follow a person's previous wishes.
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Affiliation(s)
- Jenny T. van der Steen
- Department of Public Health and Primary CareLeiden University Medical CenterLeidenThe Netherlands
- Department of Primary and Community CareRadboud university medical centerNijmegenThe Netherlands
- Radboudumc Alzheimer CenterNijmegenThe Netherlands
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Clifford K, Moreno M, Kloske CM. Navigating late-stage dementia: A perspective from the Alzheimer's Association. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2024; 16:e12530. [PMID: 38496717 PMCID: PMC10941565 DOI: 10.1002/dad2.12530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 03/19/2024]
Abstract
Alzheimer's disease (AD) is the most common cause of dementia, a general term for memory loss and decline in other cognitive abilities enough to interfere with daily life. AD accounts for 60% to 80% of dementia cases. The late stage of AD tends to be the shortest stage and, on average, lasts 1 to 2 years. As this stage of the condition progresses, it requires continuous intensive long-term care and around-the-clock intensive care. The Alzheimer's Association stands firm in its commitment to supporting individuals living with AD and other dementia, their care partners, and their health-care providers as they navigate treatment and care decisions across the continuum of the disease. This article is a direct response to recently published works that run counter to the Association's viewpoint. It outlines the Association's perspective on crucial factors for consideration during late-stage dementia care, including advanced directives, palliative care, nutrition, and legal considerations. It explores diverse perspectives from the field, differing from the Alzheimer's Association's stance. Last, it underscores resources available through the Alzheimer's Association, aiming to present a comprehensive perspective on late-stage care for support and assistance to all involved.
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Smaling HJ, Jingyuan X, Nakanishi M, Shinan-Altman S, Mehr DR, Radbruch L, Gaertner J, Werner P, Achterberg WP, van der Steen JT. Interventions that may increase control at the end of life in persons with dementia: the cross-cultural CONT-END acceptability study protocol and pilot-testing. BMC Palliat Care 2023; 22:142. [PMID: 37752467 PMCID: PMC10523619 DOI: 10.1186/s12904-023-01249-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Interventions such as advance care planning (ACP), technology, or access to euthanasia may increase the sense of control over the end of life. In people with advanced dementia, the loss of cognitive and physical function limits the ability to control care. To date, little is known about the acceptability of these interventions from the perspective of persons with dementia and others involved. This study will examine the cross-cultural acceptability, and factors associated with acceptability, of four end-of-life interventions in dementia which contain an element of striving for control. Also, we report on the development and pilot testing of animation video vignettes that explain the interventions in a standardized manner. METHODS Cross-sectional mixed-methods vignette study. We assess acceptability of two ACP approaches, technology use at the end of life and euthanasia in persons with dementia, their family caregivers and physicians in six countries (Netherlands, Japan, Israel, USA, Germany, Switzerland). We aim to include 80 participants per country, 50 physicians, 15 persons with dementia, and 15 family caregivers. After viewing each animation video, participants are interviewed about acceptability of the intervention. We will examine differences in acceptability between group and country and explore other potentially associated factors including variables indicating life view, personality, view on dementia and demographics. In the pilot study, participants commented on the understandability and clarity of the vignettes and instruments. Based on their feedback, the scripts of the animation videos were clarified, simplified and adapted to being less slanted in a specific direction. DISCUSSION In the pilot study, the persons with dementia, their family caregivers and other older adults found the adapted animation videos and instruments understandable, acceptable, feasible, and not burdensome. The CONT-END acceptability study will provide insight into cross-cultural acceptability of interventions in dementia care from the perspective of important stakeholders. This can help to better align interventions with preferences. The study will also result in a more fundamental understanding as to how and when having control at the end of life in dementia is perceived as beneficial or perhaps harmful. TRIAL REGISTRATION The CONT-END acceptability study was originally registered at the Netherlands Trial Register (NL7985) at 31 August, 2019, and can be found on the International Clinical Trials Registry Platform.
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Affiliation(s)
- Hanneke J.A. Smaling
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- University Network for the Care sector Zuid-Holland, Leiden University Medical Center, Leiden, The Netherlands
| | - Xu Jingyuan
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
| | - Miharu Nakanishi
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - David R. Mehr
- Department of Family and Community Medicine, University of Missouri, Columbia, MO USA
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Centre for Palliative Medicine, Helios Hospital Bonn/Rhein-Sieg, Bonn, Germany
| | - Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Perla Werner
- Department of Community Mental Health, University of Haifa, Haifa, Israel
| | - Wilco P. Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- University Network for the Care sector Zuid-Holland, Leiden University Medical Center, Leiden, The Netherlands
- Center for Old Age Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
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Scheeres-Feitsma TM, van Laarhoven AJJMK, de Vries R, Schaafsma P, van der Steen JT. Family involvement in euthanasia or Physician Assisted Suicide and dementia: A systematic review. Alzheimers Dement 2023; 19:3688-3700. [PMID: 37186445 DOI: 10.1002/alz.13094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To assess how families are involved in situations of euthanasia or physician assisted suicide (PAS) in dementia. DESIGN Systematic review searching literature in nine databases from inception up to October 2021. We included studies on family involvement in euthanasia from the perspective of persons with dementia and family caregivers. Themes were formulated through thematic analysis. The design was registered at Prospero (CRD42022298215). RESULTS We assessed 215 of 4038 studies in full text; 19 met the inclusion criteria of which 13 empirical studies. Themes included for people with dementia: being a burden; stage of dementia, and permissibility of euthanasia/PAS. Themes for family were the burden of care, responsibility toward the euthanasia or PAS wish, permissibility of euthanasia/PAS. CONCLUSION The wish for euthanasia/PAS arises in situations of burdensome care and fear of future deterioration. The family feels entrusted with the responsibility to enact upon the death wish. In shaping this responsibility, four roles of family can be distinguished: carer, advocate, supporter, and performer. Family as in need of support themselves is understudied.
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Affiliation(s)
| | | | - Ralph de Vries
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Jenny T van der Steen
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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Bodas M, Ziv A, Rubin C, Oberman B, Tawil Y, Shaulov A, Kaplan G, Velan B. Polarization in public attitudes toward end-of-life decisions in Israel - A cross-sectional study. Palliat Support Care 2023:1-8. [PMID: 37365823 DOI: 10.1017/s1478951523000780] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVES End-of-life (EoL) processes are a complex socio-normative and ethical phenomenon. This study aimed to generate a database of public opinion in Israel concerning EoL processes and decisions and to identify differences in attitudes across subgroups in the population, particularly based on experience as a family caregiver of a dying patient. METHODS This cross-sectional study was performed in late March 2022. The study utilized an online sample of 605 adults over the age of 50 including those who accompanied a loved one to their death in the last 3 years. Participants were requested to provide their opinions and attitudes on several aspects of EoL decisions, including truth-telling, medically assisted dying, EoL procedures, pre-death actions, and family caregivers' engagement. RESULTS While only 27% and ∼30% of participants support artificial respiration or feeding (respectively) of terminally ill patients, 66% support analgesic treatment, even at the risk of shortening life. The data show an association between religiosity and agreement with life-extending procedures. For example, while 83% of seculars support medically assisted dying, only 59% and 26% of traditional and religious respondents support it. However, no statistically significant differences were observed in support of family involvement in EoL process in any sociodemographic variable. SIGNIFICANCE OF RESULTS The results of this study suggest that the Israeli public is relatively polarized on several issues about EoL processes, specifically patient autonomy and medically assisted dying. Yet, at the same time, there is a consensus among the Israeli public about certain EoL elements, particularly the importance of family caregivers in the EoL decision-making process.
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Affiliation(s)
- Moran Bodas
- The Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
- The School of Public Health, Faculty of Medicine, Tel-Aviv University, Tel-Aviv-Yafo, Israel
| | - Arnona Ziv
- The Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
| | - Carmit Rubin
- The Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
| | - Bernice Oberman
- The Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
| | - Yoel Tawil
- The Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
| | - Adir Shaulov
- Department of Hematology, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Giora Kaplan
- The Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
| | - Baruch Velan
- The Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
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Scopetti M, Morena D, Padovano M, Manetti F, Di Fazio N, Delogu G, Ferracuti S, Frati P, Fineschi V. Assisted Suicide and Euthanasia in Mental Disorders: Ethical Positions in the Debate between Proportionality, Dignity, and the Right to Die. Healthcare (Basel) 2023; 11:healthcare11101470. [PMID: 37239756 DOI: 10.3390/healthcare11101470] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/27/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The admission of people suffering from psychiatric and neurocognitive disorders to euthanasia and physician-assisted suicide (E/PAS) in some European and non-European countries represents a controversial issue. In some countries, the initial limitation of E/PAS to cases of severe physical illness with poor prognosis in the short term has been overcome, as it was considered discriminatory; thus, E/PAS has also been made available to subjects suffering from mental disorders. This decision has raised significant ethical questions regarding the capacity and freedom of self-determination; the family, social, and economic contexts; the social consideration of the sense of dignity and the pressure on the judgment of one's personal value; the contextual therapeutic possibilities; the identification of figures involved in the validation and application; as well as the epistemological definitions of the clinical conditions in question. To these issues must be added the situation of legislative vacuum peculiar to different countries and the widespread lack of effective evaluation and control systems. Nonetheless, pessimistic indicators on global health status, availability of care and assistance, aging demographics, and socioeconomic levels suggest that there may be further pressure toward the expansion of such requests. The present paper aims to trace an international overview with the aim of providing ethical support to the debate on the matter. Precisely, the goal is the delimitation of foundations for clinical practice in the complex field of psychiatry between the recognition of the irreversibility of the disease, assessment of the state of physical and mental suffering, as well as the possibility of adopting free and informed choices.
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Affiliation(s)
- Matteo Scopetti
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy
| | - Donato Morena
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Martina Padovano
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Federico Manetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Giuseppe Delogu
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Stefano Ferracuti
- Department of Human Neuroscience, Sapienza University of Rome, 00185 Rome, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, 00185 Rome, Italy
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Gómez-Vírseda C, Gastmans C. Euthanasia in persons with advanced dementia: a dignity-enhancing care approach. JOURNAL OF MEDICAL ETHICS 2022; 48:907-914. [PMID: 34016647 DOI: 10.1136/medethics-2021-107308] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/12/2021] [Accepted: 04/20/2021] [Indexed: 06/12/2023]
Abstract
In current Western societies, increasing numbers of people express their desire to choose when to die. Allowing people to choose the moment of their death is an ethical issue that should be embedded in sound clinical and legal frameworks. In the case of persons with dementia, it raises further ethical questions such as: Does the person have the capacity to make the choice? Is the person being coerced? Who should be involved in the decision? Is the person's suffering untreatable? The use of Advance Euthanasia Directives (AED) is suggested as a way to deal with end-of-life wishes of persons with dementia. However, in the Netherlands-the only country in which this practice is legal-the experiences of patients, doctors, and relatives have been far from satisfactory.Our paper analyses this complex ethical challenge from a Dignity-Enhancing Care approach, starting from the Dutch experiences with AED as a case. We first consider the lived experiences of the different stakeholders, seeking out a dialogical-interpretative understanding of care. We aim to promote human dignity as a normative standard for end-of-life care practices. Three concrete proposals are then presented in which this approach can be operationalised in order to deal respectfully with the end-of-life choices of persons with dementia.
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Affiliation(s)
- Carlos Gómez-Vírseda
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Flanders, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Flanders, Belgium
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Marijnissen RM, Chambaere K, Oude Voshaar RC. Euthanasia in Dementia: A Narrative Review of Legislation and Practices in the Netherlands and Belgium. Front Psychiatry 2022; 13:857131. [PMID: 35722561 PMCID: PMC9201499 DOI: 10.3389/fpsyt.2022.857131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Euthanasia was first legalized in the Netherlands and Belgium in 2001 and 2002, respectively. Currently they are among the few countries that also allow euthanasia on the basis of dementia, which is still considered controversial, both from a scientific and societal perspective. To date, euthanasia in dementia constitutes a small proportion of all Dutch and Belgian euthanasia cases. However, instances are rising due to a growing awareness among the general public about the possibilities of a self-chosen end-of-life and the willingness among medical professionals to perform euthanasia in individuals diagnosed with dementia. In both countries euthanasia is allowed under strict conditions in patients with dementia and decisional capacity regarding euthanasia, while in the Netherlands an advance euthanasia directive can also replace an oral request for euthanasia in those with late-stage dementia. Judging euthanasia requests from patients with dementia is complex and the assessment of the due care criteria (especially those related to decisional capacity and unbearable suffering) requires caution and great care. In this narrative review, we reflect on the legal regulation, clinical guidelines and societal debate regarding euthanasia in dementia in the Netherlands and Belgium. By discussing the 20 years of experience with the ethical dilemmas and controversial aspects surrounding this delicate topic, we hope to inform the preparation or implementation of new legislation on euthanasia in dementia in other countries.
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Affiliation(s)
- Radboud M. Marijnissen
- Department of Psychiatry, University Medical Center Groningen UMCG, Groningen, Netherlands
| | - Kenneth Chambaere
- The End-of-Life Care Research Group, Ghent University Hospital, Ghent, Belgium
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Yun YH, Sim JA, Choi Y, Yoon H. Attitudes toward the Legalization of Euthanasia or Physician-Assisted Suicide in South Korea: A Cross-Sectional Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095183. [PMID: 35564575 PMCID: PMC9105789 DOI: 10.3390/ijerph19095183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/16/2022] [Accepted: 04/23/2022] [Indexed: 11/16/2022]
Abstract
This study aimed to investigate the general South Korean public attitudes toward the legalization of euthanasia or physician-assisted suicide (EAS) and examine the reasons underpinning these attitudes. From March–June 2021, we conducted a cross-sectional survey of a representative national sample of 1000 South Koreans aged 19 years or older. Three in four participants (76.4%) expressed positive attitudes toward the legalization of EAS. Participants who agreed with this legalization reported “meaninglessness of the rest of life” and “right to a good death” as their main reasons. Participants who disagreed with the legalization of EAS reported “respect for life”, “violation of the right to self-determination”, “risk of abuse or overuse”, and “violation of human rights” as theirs. In the multivariate logistic regression analyses, participants with poor physical status (adjusted odds ratio [aOR]: 1.41, 95%; confidence interval [CI]: 1.02–1.93) or comorbidity (aOR: 1.84, 95%; CI: 1.19–2.83) showed positive attitudes toward the legalization of EAS. In summary, most of the general South Korean population regards the legalization of EAS positively, especially participants with poor physical status or comorbidity.
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Affiliation(s)
- Young Ho Yun
- Department of Human Systems Medicine, Seoul National University College of Medicine, Seoul 03080, Korea; (Y.C.); (H.Y.)
- Department of Family Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
- Correspondence: ; Tel.: +82-2-740-8417
| | - Jin-Ah Sim
- School of AI Convergence, Hallym University, Chuncheon 200160, Korea;
| | - Yeani Choi
- Department of Human Systems Medicine, Seoul National University College of Medicine, Seoul 03080, Korea; (Y.C.); (H.Y.)
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Hyejeong Yoon
- Department of Human Systems Medicine, Seoul National University College of Medicine, Seoul 03080, Korea; (Y.C.); (H.Y.)
- College of Liberal Studies, Seoul National University, Seoul 03080, Korea
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Euthanasia and assisted suicide: An in-depth review of relevant historical aspects. Ann Med Surg (Lond) 2022; 75:103380. [PMID: 35242326 PMCID: PMC8857436 DOI: 10.1016/j.amsu.2022.103380] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/04/2022] [Accepted: 02/10/2022] [Indexed: 11/24/2022] Open
Abstract
End-of-life care is an increasingly relevant topic due to advances in biomedical research and the establishment of new disciplines in evidence-based medicine and bioethics. Euthanasia and assisted suicide are two terms widely discussed in medicine, which cause displeasure on many occasions and cause relief on others. The evolution of these terms and the events associated with their study have allowed the evaluation of cases that have established useful definitions for the legal regulation of palliative care and public policies in the different health systems. However, there are still many aspects to be elucidated and defined. Based on the above, this review aimed to compile relevant historical aspects on the evolution of euthanasia and assisted suicide, which will allow understanding the use and research of these terms. The history of euthanasia and assisted suicide has been traumatic. The church and research have been decisive in the definition of euthanasia. The legal framework on the use of euthanasia and assisted suicide has been strengthened.
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Groenewoud AS, Leijten E, Oever S, Sommeren J, Boer TA. The ethics of euthanasia in dementia: A qualitative content analysis of case summaries (2012–2020). J Am Geriatr Soc 2022; 70:1704-1716. [PMID: 35187649 PMCID: PMC9306787 DOI: 10.1111/jgs.17707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 01/03/2022] [Accepted: 01/22/2022] [Indexed: 11/26/2022]
Abstract
Background The practice of euthanasia in dementia has thus far been described both in terms of its empirical patient characteristics and its ethical questions. However, 40 new cases have been published since the last study. Methods A qualitative content analysis of all 111 Dutch case summaries of euthanasia in dementia patients between 2012 and 2020, selected from the total of 1117 cases published by the Regional Euthanasia Review Committees (RTE). Our initial analytical framework consists of six due care criteria and five ethical principles. Results 111 case summaries were analyzed, from which we distilled seven recurring ethical questions: (1) How voluntary is a request? (2) Can an incapacitated patient make well‐considered requests? (3) What constitutes “unbearable suffering”? (4) What if the unbearableness of suffering solely consists of “the absence of any prospect of improvement”? (5) What if a euthanasia request is meant to prevent future suffering (now for then)? (6) How (well) can a patient with cognitive limitations be informed? (7) What are “reasonable alternatives” and what if patients decline available alternatives? Conclusions Beyond these questions, however, we also see some serious challenges for the future: (a) narrowing the gap between perceived and real nursing home quality, since many advance euthanasia directives refer to nursing homes as sources of unbearable suffering; (b) making information to incompetent patients and their relatives about end of life options more tailor made, since it is questionable whether patients with dementia currently understand all of the euthanasia procedure; (c) involving patients' own physician as long as possible in a euthanasia request. Training may help physicians to deal better with euthanasia requests by patients suffering from dementia; (d) longitudinal research is required that encompasses all dementia euthanasia cases, not only those selected by the RTE.
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Affiliation(s)
- Antonie Stef Groenewoud
- Radboud University Medical Center, Scientific Center for Quality of Healthcare (IQ Healthcare) Nijmegen the Netherlands
- Protestant Theological University Groningen the Netherlands
| | - Ellen Leijten
- Radboud University Medical Center Nijmegen the Netherlands
| | - Sterre Oever
- Radboud University Medical Center Nijmegen the Netherlands
| | - Julia Sommeren
- Radboud University Medical Center Nijmegen the Netherlands
| | - Theodoor Adriaan Boer
- Protestant Theological University Groningen the Netherlands
- University of Sunderland Sunderland UK
- Health Council of the Netherlands The Hague the Netherlands
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Ha EH. Home-dwelling older adults' attitudes and perceptions of dementia: A Q-methodological study in South Korea. Jpn J Nurs Sci 2022; 19:e12467. [PMID: 34981635 DOI: 10.1111/jjns.12467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/15/2021] [Accepted: 11/26/2021] [Indexed: 11/30/2022]
Abstract
AIM Older adult attitudes and perceptions of dementia can have a major impact on early diagnosis, efforts to prevent and appropriately treat it, as well as being a family burden. The aim of this study is to explore attitudes and perceptions of dementia of home-dwelling older adults using Q-methodology. METHOD A total of 42 adults, age 65 or over, who live in South Korea ranked 37 Q statements about their attitudes and perceptions of dementia into A Q sort table grid. RESULTS The following three distinct viewpoints were extracted: (1) it is my responsibility to prevent and to care about dementia (family-centered view); (2) there are no ways to treat dementia (despairing views); and (3) dementia is a national responsibility (nation-centered view). CONCLUSION Based on these results, central and local government and communities should work together with older adults to manage dementia and reflect these three viewpoints when developing systematic dementia management programs.
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Affiliation(s)
- Eun-Ho Ha
- Department of Nursing, Jungwon University, Goesan-gun, South Korea
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Picón-Jaimes YA, Orozco-Chinome JE, Lozada-Martínez ID, Mass-Ramirez S, Higuera-Cetina CI, Montaña-Gómez LM, Moscote-Salazar LR, Narvaez-Rojas AR. Perception of Physicians Working in Chile Toward Assisted Suicide and Euthanasia: A Nationwide Cross-Sectional Study. J Prim Care Community Health 2022; 13:21501319221121462. [PMID: 36112863 PMCID: PMC9476241 DOI: 10.1177/21501319221121462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Assisted suicide and euthanasia are controversial issues today and have been throughout the history of humanity, mainly because there are individuals for and against them. Currently, the legalization of these practices is being discussed in Chile, and the perception of physicians regarding this issue is unknown. Therefore, this study aimed to assess physicians' perception of Chile's euthanasia and assisted suicide. METHODS A nationwide cross-sectional study was carried out in Chile. A questionnaire of physicians' attitudes and opinions on assisted suicide and euthanasia was used. The population was the doctors who work in Chile, and the sample was convenient with a sample calculation of 384 physicians. About 20 variables were considered and included in a form created through the Google forms option, which was distributed through social networks: LinkedIn, Facebook, Twitter, and WhatsApp. To guarantee the anonymity of the participants, the option to request and remember the participant's email was deactivated. A generated database allowed the quantitative analysis of the variables and their expression through frequencies, percentages, and graphs. The European University of the Atlantic's research ethics committee approved this study as stated in the document CE-55 of March 2021. RESULTS A total of 410 physicians were surveyed. 50.7% (n = 208) of the participants identified themselves as men, and 69.8% (n = 286) were Chilean. The city of Santiago was the area of residence of 72.9% (n = 299) of the participants. About 34.6% (n = 142) of participants were general practitioners, and 39.3% (n = 161) of the physicians had more than 20 years of experience. About 68.7% had favorable attitudes toward euthanasia and 54.4% toward assisted suicide; However, although the majority favored legalizing euthanasia and assisted suicide, approximately 48.8% stated that they would not participate in an assisted suicide procedure. CONCLUSIONS There was evidence of support for the implementation and legalization of euthanasia and assisted suicide by physicians in Chile. However, there are still professionals who have not yet decided on a definitive position on these practices.
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Affiliation(s)
| | | | - Iván David Lozada-Martínez
- International Coalition on Surgical Research, Bogotá, Colombia.,Universidad de Cartagena, Cartagena, Colombia
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Rajkumar RP. Physician-Assisted Suicide in Dementia: Paradoxes, Pitfalls and the Need for Prudence. FRONTIERS IN SOCIOLOGY 2021; 6:815233. [PMID: 35004941 PMCID: PMC8727695 DOI: 10.3389/fsoc.2021.815233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/07/2021] [Indexed: 06/14/2023]
Abstract
There has been an increasing drive towards the legalization of physician-assisted suicide (PAS) in patients with dementia, particularly in patients with advanced disease and severe cognitive impairment. Advocacy for this position is often based on utilitarian philosophical principles, on appeals to the quality of life of the patient and their caregiver(s), or on economic constraints faced by caregivers as well as healthcare systems. In this paper, two lines of evidence against this position are presented. First, data on attitudes towards euthanasia for twenty-eight countries, obtained from the World Values Survey, is analyzed. An examination of this data shows that, paradoxically, positive attitudes towards this procedure are found in more economically advanced countries, and are strongly associated with specific cultural factors. Second, the literature on existing attitudes towards PAS in cases of dementia, along with ethical arguments for and against the practice, is reviewed and specific hazards for patients, caregivers and healthcare professionals are identified. On the basis of these findings, the author suggests that the practice of PAS in dementia is not one that can be widely or safely endorsed, on both cultural and ethical grounds. Instead, the medical field should work in collaboration with governmental, social welfare and patient advocacy services to ensure optimal physical, emotional and financial support to this group of patients and their caregivers.
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The Limits of Advance Directives in Maintaining Autonomy in Patients with Advanced Dementia. Am J Med 2021; 134:963-967. [PMID: 33811883 DOI: 10.1016/j.amjmed.2021.02.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 11/23/2022]
Abstract
As dementia becomes more prevalent in the aging population, clinicians increasingly face the challenge of caring for patients who had told family members that they preferred death to life with advanced dementia. Advance directives can guide management, but usually are inadequate in caring for patients with advanced dementia. The "now" patient has very different sensibilities than the "then" patient who had expressed preferences for terminal care before dementia severely impaired cognition and executive function. Clinicians lack clear means of following a patient's directive to die rather than to live with advanced dementia. Withholding life-sustaining oral feeding or fluids is ethically problematic. Controversies remain over precedent autonomy as the justification for advance dementia directives, and the consequent legal, ethical, and practical issues clinicians face, particularly involving feeding.
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van der Steen JT, Heck S, Juffermans CC, Garvelink MM, Achterberg WP, Clayton J, Thompson G, Koopmans RT, van der Linden YM. Practitioners' perceptions of acceptability of a question prompt list about palliative care for advance care planning with people living with dementia and their family caregivers: a mixed-methods evaluation study. BMJ Open 2021; 11:e044591. [PMID: 33846153 PMCID: PMC8048016 DOI: 10.1136/bmjopen-2020-044591] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES In oncology and palliative care, patient question prompt lists (QPLs) with sample questions for patient and family increased patients' involvement in decision-making and improved outcomes if physicians actively endorsed asking questions. Therefore, we aim to evaluate practitioners' perceptions of acceptability and possible use of a QPL about palliative and end-of-life care in dementia. DESIGN Mixed-methods evaluation study of a QPL developed with family caregivers and experts comprising a survey and interviews with practitioners. SETTING Two academic medical training centres for primary and long-term care in the Netherlands. PARTICIPANTS Practitioners (n=66; 73% woman; mean of 21 (SD 11) years of experience) who were mostly general practitioners and elderly care physicians. OUTCOMES The main survey outcome was acceptability measured with a 15-75 acceptability scale with ≥45 meaning 'acceptable'. RESULTS The survey response rate was 21% (66 of 320 participated). The QPL was regarded as acceptable (mean 51, SD 10) but 64% felt it was too long. Thirty-five per cent would want training to be able to answer the questions. Those who felt unable to answer (31%) found the QPL less acceptable (mean 46 vs 54 for others; p=0.015). We identified three themes from nine interviews: (1) enhancing conversations through discussing difficult topics, (2) proactively engaging in end-of-life conversations and (3) possible implementation. CONCLUSION Acceptability of the QPL was adequate, but physicians feeling confident to be able to address questions about end-of-life care is crucial when implementing it in practice, and may require training. To facilitate discussions of advance care planning and palliative care, families and persons with dementia should also be empowered to access the QPL themselves.
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Affiliation(s)
- Jenny T van der Steen
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Sten Heck
- Leiden University, Leiden, The Netherlands
| | - Carla Cm Juffermans
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Wilco P Achterberg
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Josephine Clayton
- Centre for Learning & Research in Palliative Care, Hammond Care, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney Northern Clinical School, Sydney, New South Wales, Australia
| | - Genevieve Thompson
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Raymond Tcm Koopmans
- Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Radboud university medical center, Nijmegen, The Netherlands
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