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Riisfeldt TD. Euthanasia and Assisted Suicide Are Compatible with Palliative Care and Are Not Rendered Redundant by It. Camb Q Healthc Ethics 2023; 32:1-9. [PMID: 36693814 DOI: 10.1017/s0963180122000706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
It is often argued by health professionals working within the field of palliative care that palliative care and euthanasia/assisted suicide are incompatible. Across the literature, this claim is grounded on the three claims that (1) palliative care and euthanasia/assisted suicide have different aims, (2) euthanasia/assisted suicide is at odds with the doctor's fundamental role as a healer, and (3) euthanasia/assisted suicide constitutes patient abandonment. Furthermore, even if palliative care and euthanasia/assisted suicide are compatible, it is often argued that the availability of palliative care renders euthanasia/assisted suicide redundant. This depends on two claims that (1) palliative care is always available and effective, and (2) palliative care is always preferable to euthanasia/assisted suicide. This article argues that all of these claims are false, ultimately aiming to establish that palliative care and euthanasia/assisted suicide are complementary rather than mutually exclusive.
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Affiliation(s)
- Thomas D Riisfeldt
- Department of Philosophy, University of New South Wales, Sydney, New South Wales, Australia
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Worthington A, Regnard C, Sleeman KE, Finlay I. Comparison of official reporting on assisted suicide and euthanasia across jurisdictions. BMJ Support Palliat Care 2022:spcare-2022-003944. [PMID: 36585221 DOI: 10.1136/spcare-2022-003944] [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: 08/29/2022] [Accepted: 12/08/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Official data reports from countries where assisted suicide and euthanasia is legal are an important resource for discerning participation rates, patient safety and transparency in the way that assisted dying is legal. We aimed to identify what information is published in official data reports on assisted suicide and euthanasia across jurisdictions. METHODS We searched for official data reports from every jurisdiction where assisted suicide or euthanasia is legal. Searches were conducted on these countries' official health authority websites as well as on mainstream search engines. The data measures included within each report were described in four categories: participation data, patient characteristics, clinician characteristics, and drugs and dying process. RESULTS We found that 16 jurisdictions where assisted suicide or euthanasia is currently legal regularly publish data reports regarding its practice. The information included within these official reports varies greatly, with few measures published across all or most jurisdictions. CONCLUSIONS Differences in the kinds of information published within official reports on assisted suicide and euthanasia makes comparing the practice of assisted suicide and euthanasia across jurisdictions challenging. Many jurisdictions fail to report data measures, which could be valuable to the understanding of assisted suicide and euthanasia practices within that country. Improving data reporting across jurisdictions where assisted suicide and euthanasia is legal, for example, through establishing minimum requirements for data collection and reporting, is an important step towards ensuring patient safety and the transparent practice of assisted suicide and euthanasia.
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Affiliation(s)
- Ana Worthington
- Department of Theology and Religion, University of Oxford, Oxford, UK
| | - Claud Regnard
- Department of Palliative Medicine, St. Oswald's Hospice, Newcastle upon Tyne, UK
| | | | - Ilora Finlay
- Department of Palliative Medicine, Cardiff University, Cardiff, UK
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3
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Frey R, Balmer D. The views of Aotearoa/New Zealand adults over 60 years regarding the End of Life Choice Act 2019. JOURNAL OF RELIGION AND HEALTH 2022; 61:1605-1620. [PMID: 34355303 PMCID: PMC8340805 DOI: 10.1007/s10943-021-01359-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/18/2021] [Indexed: 06/13/2023]
Abstract
This study described the views of older New Zealand adults toward assisted dying and specifically the End of Life Choice Act (2019), an Act making assisted dying legal. An anonymous postal and online survey of 636 adults 60 years and older was conducted. The majority of respondents did not support legalization (85.7%), while 8.8% were in favor (5.5% did not specify a view). Weighted binary logistic regression indicated that the odds of support for legalization were lower in those respondents with a religious affiliation (OR = .020, S.E. = 0.60, p = .00), and there were 2.66 times greater odds in those identifying as male (S.E. = 0.34, p = .005). On the other hand, those respondents under 65 years had increased odds of supporting legalization (OR = 1.89, S.E. = .029, p = .045). Results indicate that most participants were concerned about potential abuses and coercive practices if assisted dying became legally available in New Zealand.
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Affiliation(s)
- Rosemary Frey
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand.
| | - Deborah Balmer
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
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4
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Sameer A, Khan M. Knowledge, awareness, and attitude of health professions student's towards end-of-life patient care. ARCHIVES OF MENTAL HEALTH 2021. [DOI: 10.4103/amh.amh_59_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Gamondi C, Borasio GD, Oliver P, Preston N, Payne S. Responses to assisted suicide requests: an interview study with Swiss palliative care physicians. BMJ Support Palliat Care 2017; 9:e7. [DOI: 10.1136/bmjspcare-2016-001291] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 06/23/2017] [Accepted: 07/18/2017] [Indexed: 11/03/2022]
Abstract
ObjectivesAssisted suicide in Switzerland is mainly performed by right-to-die societies. Medical involvement is limited to the prescription of the drug and certification of eligibility. Palliative care has traditionally been perceived as generally opposed to assisted suicide, but little is known about palliative care physicians’ involvement in assisted suicide practices. This paper aims to describe their perspectives and involvement in assisted suicide practices.MethodsA qualitative interview study was conducted with 23 palliative care physicians across Switzerland. Thematic analysis was used to interpret data.ResultsSwiss palliative care physicians regularly receive assisted suicide requests while none reported having received specific training in managing these requests. Participants reported being involved in assisted suicide decision making most were not willing to prescribe the lethal drug. After advising patients of the limits on their involvement in assisted suicide, the majority explored the origins of the patient’s request and offered alternatives. Many participants struggled to reconcile their understanding of palliative care principles with patients’ wishes to exercise their autonomy. The majority of participants had no direct contact with right-to-die societies, many desired better collaboration. A desire was voiced for a more structured debate on assisted suicide availability in hospitals and clearer legal and institutional frameworks.ConclusionsThe Swiss model of assisted suicide gives palliative care physicians opportunities to develop roles which are compatible with each practitioner’s values, but may not correspond to patients’ expectations. Specific education for all palliative care professionals and more structured ways to manage communication about assisted suicide are warranted.
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Bernheim JL, Raus K. Euthanasia embedded in palliative care. Responses to essentialistic criticisms of the Belgian model of integral end-of-life care. JOURNAL OF MEDICAL ETHICS 2017; 43:489-494. [PMID: 28062650 DOI: 10.1136/medethics-2016-103511] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 10/25/2016] [Accepted: 12/01/2016] [Indexed: 06/06/2023]
Abstract
The Belgian model of 'integral' end-of-life care consists of universal access to palliative care (PC) and legally regulated euthanasia. As a first worldwide, the Flemish PC organisation has embedded euthanasia in its practice. However, some critics have declared the Belgian-model concepts of 'integral PC' and 'palliative futility' to fundamentally contradict the essence of PC. This article analyses the various essentialistic arguments for the incompatibility of euthanasia and PC. The empirical evidence from the euthanasia-permissive Benelux countries shows that since legalisation, carefulness (of decision making) at the end of life has improved and there have been no significant adverse 'slippery slope' effects. It is problematic that some critics disregard the empirical evidence as epistemologically irrelevant in a normative ethical debate. Next, rejecting euthanasia because its prevention was a founding principle of PC ignores historical developments. Further, critics' ethical positions depart from the PC tenet of patient centeredness by prioritising caregivers' values over patients' values. Also, many critics' canonical adherence to the WHO definition of PC, which has intention as the ethical criterion is objectionable. A rejection of the Belgian model on doctrinal grounds also has nefarious practical consequences such as the marginalisation of PC in euthanasia-permissive countries, the continuation of clandestine practices and problematic palliative sedation until death. In conclusion, major flaws of essentialistic arguments against the Belgian model include the disregard of empirical evidence, appeals to canonical and questionable definitions, prioritisation of caregiver perspectives over those of patients and rejection of a plurality of respectable views on decision making at the end of life.
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Affiliation(s)
- Jan L Bernheim
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussel, Belgium
| | - Kasper Raus
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussel, Belgium
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Sheahan L. Exploring the interface between 'physician-assisted death' and palliative care: cross-sectional data from Australasian palliative care specialists. Intern Med J 2017; 46:443-51. [PMID: 26762669 DOI: 10.1111/imj.13009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 12/10/2015] [Accepted: 12/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Legalisation of physician-assisted dying (PAD) remains a highly contested issue. In the Australasian context, the opinion and perspective of palliative care specialists have not been captured empirically, and are required to inform better the debate around this issue, moving forward. AIM To identify current attitudes and experiences of palliative care specialists in Australasia regarding requests for physician-assisted suicide and voluntary euthanasia, and to capture the opinion of palliative care specialists on the legalisation of these practices in the Australasian context. METHOD An anonymous, cross-sectional, online survey of Australasian specialists in palliative care, addressing the following six areas: (i) demographics; (ii) frequency of requests, and response given; (iii) understanding of the term 'voluntary euthanasia'; (iv) opinion regarding legalisation of physician-assisted suicide and voluntary euthanasia in Australasia, and willingness to participate if legal; (v) identification of the most important values guiding this opinion; and (vi) anticipated impact that legalisation of assisted death would have on palliative care practice. RESULTS Important findings include: (i) palliative care specialists are largely opposed to the legalisation of PAD; (ii) the proportional titration of opioids is not understood by any palliative care specialist studied to be 'voluntary euthanasia'; and (iii) there is a wide variation in frequency of requests, and one-third of palliative care specialists express discomfort in dealing with requests for assisted suicide or euthanasia. CONCLUSION Key areas for future research at the interface between PAD and best practice end-of-life care are identified, including exploration into why palliative care specialists are largely opposed to PAD, and consideration of the impact 'the opioid misconception' may have on the literature informing this debate.
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Affiliation(s)
- L Sheahan
- St George and Calvary Hospitals, Sydney, New South Wales, Australia.,Centre for Values Ethics and the Law in Medicine, University of Sydney, Sydney, New South Wales, Australia.,Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada.,School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Barutta J, Vollmann J. Physician-assisted death with limited access to palliative care. JOURNAL OF MEDICAL ETHICS 2015; 41:652-654. [PMID: 25614156 DOI: 10.1136/medethics-2013-101953] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 01/08/2015] [Indexed: 06/04/2023]
Abstract
Even among advocates of legalising physician-assisted death, many argue that this should be done only once palliative care has become widely available. Meanwhile, according to them, physician-assisted death should be banned. Four arguments are often presented to support this claim, which we call the argument of lack of autonomy, the argument of existing alternatives, the argument of unfair inequalities and the argument of the antagonism between physician-assisted death and palliative care. We argue that although these arguments provide strong reasons to take appropriate measures to guarantee access to good quality palliative care to everyone who needs it, they do not justify a ban on physician-assisted death until we have achieved this goal.
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Affiliation(s)
- Joaquín Barutta
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany Department of Medical Humanities, Italian Hospital University, Buenos Aires, Argentina
| | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
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Physician-assisted suicide and/or euthanasia: Pragmatic implications for palliative care [corrected]. Palliat Support Care 2015; 13:1399-409. [PMID: 25670161 DOI: 10.1017/s1478951515000176] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Despite the availability of palliative care in many countries, legalization of euthanasia and physician-assisted suicide (EAS) continues to be debated-particularly around ethical and legal issues--and the surrounding controversy shows no signs of abating. Responding to EAS requests is considered one of the most difficult healthcare responsibilities. In the present paper, we highlight some of the less frequently discussed practical implications for palliative care provision if EAS were to be legalized. Our aim was not to take an explicit anti-EAS stance or expand on findings from systematic reviews or philosophical and ethico-legal treatises, but rather to offer clinical perspectives and the potential pragmatic implications of legalized EAS for palliative care provision, patients and families, healthcare professionals, and the broader community. METHOD We provide insights from our multidisciplinary clinical experience, coupled with those from various jurisdictions where EAS is, or has been, legalized. RESULTS We believe that these issues, many of which are encountered at the bedside, must be considered in detail so that the pragmatic implications of EAS can be comprehensively considered. SIGNIFICANCE OF RESULTS Increased resources and effort must be directed toward training, research, community engagement, and ensuring adequate resourcing for palliative care before further consideration is given to allocating resources for legalizing euthanasia and physician-assisted suicide.
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Rys S, Deschepper R, Mortier F, Deliens L, Bilsen J. Continuous Sedation Until Death With or Without the Intention to Hasten Death—A Nationwide Study in Nursing Homes in Flanders, Belgium. J Am Med Dir Assoc 2014; 15:570-5. [DOI: 10.1016/j.jamda.2014.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/01/2014] [Accepted: 04/04/2014] [Indexed: 10/25/2022]
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Malpas PJ, Wilson MKR, Rae N, Johnson M. Why do older people oppose physician-assisted dying? A qualitative study. Palliat Med 2014; 28:353-9. [PMID: 24280276 DOI: 10.1177/0269216313511284] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Physician-assisted dying at the end of life has become a significant issue of public discussion. While legally available in a number of countries and jurisdictions, it remains controversial and illegal in New Zealand. AIM The study aimed to explore the reasons some healthy older New Zealanders oppose physician-assisted dying in order to inform current debate. DESIGN Recorded interviews were transcribed and analysed by the authors after some edits had been made by respondents. SETTING/PARTICIPANTS In all, 11 older participants (over 65 years) who responded to advertisements placed in Grey Power magazines and a University of Auckland email list were interviewed for around 1 h and asked a number of open-ended questions. RESULTS Four central themes opposing physician-assisted dying were identified from the interviews: one's personal experience with health care and dying and death, religious reasoning and beliefs, slippery slope worries and concern about potential abuses if physician-assisted dying were legalised. CONCLUSIONS An important finding of the study suggests that how some older individuals think about physician-assisted dying is strongly influenced by their past experiences of dying and death. While some participants had witnessed good, well-managed dying and death experiences which confirmed for them the view that physician-assisted dying was unnecessary, those who had witnessed poor dying and death experiences opposed physician-assisted dying on the grounds that such practices could come to be abused by others.
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Affiliation(s)
- Phillipa J Malpas
- 1Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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12
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Chambaere K, Rietjens JAC, Cohen J, Pardon K, Deschepper R, Pasman HRW, Deliens L. Is educational attainment related to end-of-life decision-making? A large post-mortem survey in Belgium. BMC Public Health 2013; 13:1055. [PMID: 24207110 PMCID: PMC3840665 DOI: 10.1186/1471-2458-13-1055] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 11/05/2013] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Kenneth Chambaere
- End-of-life Care Research Group, Vrije Universiteit Brussel & Ghent University, Laarbeeklaan 103, Brussel 1090, Belgium.
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Hains CAM, Hulbert-Williams NJ. Attitudes toward euthanasia and physician-assisted suicide: a study of the multivariate effects of healthcare training, patient characteristics, religion and locus of control. JOURNAL OF MEDICAL ETHICS 2013; 39:713-6. [PMID: 23378530 DOI: 10.1136/medethics-2012-100729] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Public and healthcare professionals differ in their attitudes towards euthanasia and physician-assisted suicide (PAS), the legal status of which is currently in the spotlight in the UK. In addition to medical training and experience, religiosity, locus of control and patient characteristics (eg, patient age, pain levels, number of euthanasia requests) are known influencing factors. Previous research tends toward basic designs reporting on attitudes in the context of just one or two potentially influencing factors; we aimed to test the comparative importance of a larger range of variables in a sample of nursing trainees and non-nursing controls. One hundred and fifty-one undergraduate students (early-stage nursing training, late-stage nursing training and non-nursing controls) were approached on a UK university campus and asked to complete a self-report questionnaire. Participants were of mixed gender and were on average 25.5 years old. No significant differences in attitude were found between nursing and non-nursing students. There was a significant positive correlation between higher religiosity and positive attitude toward euthanasia (r=0.19, p<0.05) and a significant negative relationship between internal locus of control and positive attitude toward PAS (r=-0.263, p<0.01). Multivariate analyses revealed differing predictor models for attitudes towards euthanasia and PAS, and confirm the importance of individual differences in determining these attitudes. The unexpected direction of association between religiosity and attitudes may reflect a broader cultural shift in attitudes since earlier research in this area. Furthermore, these findings suggest it possible that experience, more than training itself, may be a bigger influence on attitudinal differences in healthcare professionals.
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Age-based disparities in end-of-life decisions in Belgium: a population-based death certificate survey. BMC Public Health 2012; 12:447. [PMID: 22708727 PMCID: PMC3489592 DOI: 10.1186/1471-2458-12-447] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 04/12/2012] [Indexed: 11/17/2022] Open
Abstract
Background A growing body of scientific research is suggesting that end-of-life care and decision making may differ between age groups and that elderly patients may be the most vulnerable to exclusion of due care at the end of life. This study investigates age-related disparities in the rate of end-of-life decisions with a possible or certain life shortening effect (ELDs) and in the preceding decision making process in Flanders, Belgium in 2007, where euthanasia was legalised in 2002. Comparing with data from an identical survey in 1998 we also study the plausibility of the ‘slippery slope’ hypothesis which predicts a rise in the rate of administration of life ending drugs without patient request, especially among elderly patients, in countries where euthanasia is legal. Method We performed a post-mortem survey among physicians certifying a large representative sample (n = 6927) of death certificates in 2007, identical to a 1998 survey. Response rate was 58.4%. Results While the rates of non-treatment decisions (NTD) and administration of life ending drugs without explicit request (LAWER) did not differ between age groups, the use of intensified alleviation of pain and symptoms (APS) and euthanasia/assisted suicide (EAS), as well as the proportion of euthanasia requests granted, was bivariately and negatively associated with patient age. Multivariate analysis showed no significant effects of age on ELD rates. Older patients were less often included in decision making for APS and more often deemed lacking in capacity than were younger patients. Comparison with 1998 showed a decrease in the rate of LAWER in all age groups except in the 80+ age group where the rate was stagnant. Conclusion Age is not a determining factor in the rate of end-of-life decisions, but is in decision making as patient inclusion rates decrease with old age. Our results suggest there is a need to focus advance care planning initiatives on elderly patients. The slippery slope hypothesis cannot be confirmed either in general or among older people, as since the euthanasia law fewer LAWER cases were found.
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Pereira J. Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls. ACTA ACUST UNITED AC 2011; 18:e38-45. [PMID: 21505588 DOI: 10.3747/co.v18i2.883] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Euthanasia or assisted suicide-and sometimes both-have been legalized in a small number of countries and states. In all jurisdictions, laws and safeguards were put in place to prevent abuse and misuse of these practices. Prevention measures have included, among others, explicit consent by the person requesting euthanasia, mandatory reporting of all cases, administration only by physicians (with the exception of Switzerland), and consultation by a second physician.The present paper provides evidence that these laws and safeguards are regularly ignored and transgressed in all the jurisdictions and that transgressions are not prosecuted. For example, about 900 people annually are administered lethal substances without having given explicit consent, and in one jurisdiction, almost 50% of cases of euthanasia are not reported. Increased tolerance of transgressions in societies with such laws represents a social "slippery slope," as do changes to the laws and criteria that followed legalization. Although the initial intent was to limit euthanasia and assisted suicide to a last-resort option for a very small number of terminally ill people, some jurisdictions now extend the practice to newborns, children, and people with dementia. A terminal illness is no longer a prerequisite. In the Netherlands, euthanasia for anyone over the age of 70 who is "tired of living" is now being considered. Legalizing euthanasia and assisted suicide therefore places many people at risk, affects the values of society over time, and does not provide controls and safeguards.
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Affiliation(s)
- J Pereira
- Division of Palliative Care, University of Ottawa; Department of Palliative Medicine, Bruyère Continuing Care; and Palliative Care Service, The Ottawa Hospital, Ottawa, ON
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Chambaere K, Bilsen J, Cohen J, Onwuteaka-Philipsen BD, Mortier F, Deliens L. Trends in medical end-of-life decision making in Flanders, Belgium 1998-2001-2007. Med Decis Making 2010; 31:500-10. [PMID: 21191121 DOI: 10.1177/0272989x10392379] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In 2002, Belgium saw the enactment of 3 laws concerning euthanasia, palliative care, and patient rights that are likely to affect end-of-life decision making. This report examines trends in the occurrence and decision-making process of end-of-life practices in different patient groups since these legal changes. A large-scale retrospective survey in Flanders, Belgium, previously conducted in 1998 and 2001, was repeated in 2007. Questionnaires regarding end-of-life practices and the preceding decision-making process were mailed to physicians who certified a representative sample (N = 6927) of death certificates. The 2007 response rate was 58.4%. In patient groups in which the prevalence of life-ending drug use without explicit patient request has dropped, performance of euthanasia and assisted suicide has increased. The consistent increase in intensified pain and symptom alleviation was found in all patient groups except cancer patients. In 2007, competent patients were slightly more often involved in the discussion of end-of-life practices than in previous years. Over the years, involvement of the patient in decision making was consistently more likely among younger patients, cancer patients, and those dying at home. Physicians consulted their colleagues more often than in previous years for euthanasia and nontreatment decisions. The euthanasia law and emerging palliative care culture have substantially affected the occurrence and decision making for end-of-life practices in Belgium. Efforts are still needed to encourage shared end-of-life decision making, as some patients would benefit from advance care planning.
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Affiliation(s)
- Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium (KC, JB, JC, LD)
| | - Johan Bilsen
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium (KC, JB, JC, LD)
- Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium (JB)
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium (KC, JB, JC, LD)
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, the Netherlands (BDOP, LD)
| | - Freddy Mortier
- Bioethics Institute Ghent, Ghent University, Ghent, Belgium (FM)
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium (KC, JB, JC, LD)
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, the Netherlands (BDOP, LD)
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Enck RE. Physician-Assisted Dying. Am J Hosp Palliat Care 2010; 27:441-3. [DOI: 10.1177/1049909110376806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Robert E. Enck
- East Tennessee State University College of Medicine, Johnson City, TN, USA,
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Smets T, Bilsen J, Cohen J, Rurup ML, Mortier F, Deliens L. Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases. BMJ 2010; 341:c5174. [PMID: 20923842 PMCID: PMC2950259 DOI: 10.1136/bmj.c5174] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2010] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To estimate the rate of reporting of euthanasia cases to the Federal Control and Evaluation Committee and to compare the characteristics of reported and unreported cases of euthanasia. Design Cross sectional analysis. Setting Flanders, Belgium. PARTICIPANTS A stratified at random sample was drawn of people who died between 1 June 2007 and 30 November 2007. The certifying physician of each death was sent a questionnaire on end of life decision making in the death concerned. MAIN OUTCOME MEASURES The rate of euthanasia cases reported to the Federal Control and Evaluation Committee; physicians' reasons for not reporting cases of euthanasia; the relation between reporting and non-reporting and the characteristics of the physician and patient; the time by which life was shortened according to the physician; the labelling of the end of life decision by the physician involved; and differences in characteristics of due care between reported and unreported euthanasia cases. RESULTS The survey response rate was 58.4% (3623/6202 eligible cases). The estimated total number of cases of euthanasia in Flanders in 2007 was 1040 (95% CI 970 to 1109), thus the incidence of euthanasia was estimated as 1.9% of all deaths (95% CI 1.6% to 2.3%). Approximately half (549/1040 (52.8%, 95% CI 43.9% to 60.5%)) of all estimated cases of euthanasia were reported to the Federal Control and Evaluation Committee. Physicians who perceived their case as euthanasia reported it in 93.1% (67/72) of cases. Cases of euthanasia were reported less often when the time by which life was shortened was less than one week compared with when the perceived life shortening was greater (37.3% v 74.1%; P<0.001). Unreported cases were generally dealt with less carefully than reported cases: a written request for euthanasia was more often absent (87.7% v 17.6% verbal request only; P<0.001), other physicians and caregivers specialised in palliative care were consulted less often (54.6% v 97.5%; 33.0% v 63.9%; P<0.001 for both), the life ending act was more often performed with opioids or sedatives (92.1% v 4.4%; P<0.001), and the drugs were more often administered by a nurse (41.3% v 0.0%; P<0.001). CONCLUSIONS One out of two euthanasia cases is reported to the Federal Control and Evaluation Committee. Most non-reporting physicians do not perceive their act as euthanasia. Countries debating legalisation of euthanasia should simultaneously consider developing a policy facilitating the due care and reporting obligations of physicians.
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Affiliation(s)
- Tinne Smets
- End of Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.
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Chambaere K, Bilsen J, Cohen J, Onwuteaka-Philipsen BD, Mortier F, Deliens L. Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey. CMAJ 2010; 182:895-901. [PMID: 20479044 PMCID: PMC2882449 DOI: 10.1503/cmaj.091876] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Legalization of euthanasia and physician-assisted suicide has been heavily debated in many countries. To help inform this debate, we describe the practices of euthanasia and assisted suicide, and the use of life-ending drugs without an explicit request from the patient, in Flanders, Belgium, where euthanasia is legal. METHODS We mailed a questionnaire regarding the use of life-ending drugs with or without explicit patient request to physicians who certified a representative sample (n = 6927) of death certificates of patients who died in Flanders between June and November 2007. RESULTS The response rate was 58.4%. Overall, 208 deaths involving the use of life-ending drugs were reported: 142 (weighted prevalence 2.0%) were with an explicit patient request (euthanasia or assisted suicide) and 66 (weighted prevalence 1.8%) were without an explicit request. Euthanasia and assisted suicide mostly involved patients less than 80 years of age, those with cancer and those dying at home. Use of life-ending drugs without an explicit request mostly involved patients 80 years of older, those with a disease other than cancer and those in hospital. Of the deaths without an explicit request, the decision was not discussed with the patient in 77.9% of cases. Compared with assisted deaths with the patient's explicit request, those without an explicit request were more likely to have a shorter length of treatment of the terminal illness, to have cure as a goal of treatment in the last week, to have a shorter estimated time by which life was shortened and to involve the administration of opioids. INTERPRETATION Physician-assisted deaths with an explicit patient request (euthanasia and assisted suicide) and without an explicit request occurred in different patient groups and under different circumstances. Cases without an explicit request often involved patients whose diseases had unpredictable end-of-life trajectories. Although opioids were used in most of these cases, misconceptions seem to persist about their actual life-shortening effects.
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Affiliation(s)
- Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.
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Seale C. Hastening death in end-of-life care: A survey of doctors. Soc Sci Med 2009; 69:1659-66. [DOI: 10.1016/j.socscimed.2009.09.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Indexed: 12/22/2022]
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The medical practice of euthanasia in Belgium and The Netherlands: Legal notification, control and evaluation procedures. Health Policy 2009; 90:181-7. [DOI: 10.1016/j.healthpol.2008.10.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 10/06/2008] [Accepted: 10/06/2008] [Indexed: 11/22/2022]
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van Marwijk H, Haverkate I, van Royen P, The AM. Impact of euthanasia on primary care physicians in the Netherlands. Palliat Med 2007; 21:609-14. [PMID: 17942499 DOI: 10.1177/0269216307082475] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is only limited knowledge about the emotional impact that performing euthanasia has on primary care physicians (PCPs) in the Netherlands. OBJECTIVE To obtain more insight into the emotional impact on PCPs of performing euthanasia or assisted suicide, and to tailor the educational needs of vocational PCP trainees accordingly. METHODS Qualitative research, consisting of four focus group studies. The setting was primary care in the Netherlands; 22 PCPs participated, in four groups (older males, older females, younger males and a group with interest with regard to euthanasia). RESULTS Various phases with different emotions were distinguished: before (tension), during (loss) and after (relief) the event. Although it is a very rare occurrence, euthanasia has a major impact on PCPs. Their relationship with the patient, their loneliness, the role of the family, and pressure from society are the main issues that emerged. Making sufficient emotional space and time available to take leave adequately from a patient is important for PCPs. CONCLUSIONS Many PCPs stressed that young physicians should form their own opinions about euthanasia and other end-of-life decisions early on in their career. We recommend that these issues are officially included in the vocational training programme for general practice.
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Affiliation(s)
- Harm van Marwijk
- Department of General Practice, EMGO Institute, VU University Medical Centre, BT Amsterdam, The Netherlands.
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Hicks MHR. Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors. BMC FAMILY PRACTICE 2006; 7:39. [PMID: 16792812 PMCID: PMC1550404 DOI: 10.1186/1471-2296-7-39] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2006] [Accepted: 06/22/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND A bill to legalize physician-assisted suicide in the UK recently made significant progress in the British House of Lords and will be reintroduced in the future. Until now there has been little discussion of the clinical implications of physician-assisted suicide for the UK. This paper describes problematical issues that became apparent from a review of the medical and psychiatric literature as to the potential effects of legalized physician-assisted suicide. DISCUSSION Most deaths by physician-assisted suicide are likely to occur for the illness of cancer and in the elderly. GPs will deal with most requests for assisted suicide. The UK is likely to have proportionately more PAS deaths than Oregon due to the bill's wider application to individuals with more severe physical disabilities. Evidence from other countries has shown that coercion and unconscious motivations on the part of patients and doctors in the form of transference and countertransference contribute to the misapplication of physician-assisted suicide. Depression influences requests for hastened death in terminally ill patients, but is often under-recognized or dismissed by doctors, some of whom proceed with assisted death anyway. Psychiatric evaluations, though helpful, do not solve these problems. Safeguards that are incorporated into physician-assisted suicide criteria probably decrease but do not prevent its misapplication. SUMMARY The UK is likely to face significant clinical problems arising from physician-assisted suicide if it is legalized. Terminally ill patients with mental illness, especially depression, are particularly vulnerable to the misapplication of physician-assisted suicide despite guidelines and safeguards.
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Affiliation(s)
- Madelyn Hsiao-Rei Hicks
- Section of Community (PRiSM), Department of Health Services Research, Institute of Psychiatry, King's College London, University of London, UK.
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Pasterfield D, Wilkinson C, Finlay IG, Neal RD, Hulbert NJ. GPs' views on changing the law on physician-assisted suicide and euthanasia, and willingness to prescribe or inject lethal drugs: a survey from Wales. Br J Gen Pract 2006; 56:450-2. [PMID: 16762127 PMCID: PMC1839020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
If physician-assisted suicide/euthanasia is legalised in the UK, this may be the work of GPs. In the absence of recent or comprehensive evidence about GPs' views on either legalisation or willingness to take part, a questionnaire survey of all Welsh GPs was conducted of whom 1202 (65%) responded. Seven hundred and fifty (62.4% of responders) and 671 (55.8% of responders) said that they did not favour a change in the law to allow physician-assisted suicide/voluntary euthanasia respectively. These data provide a rational basis for determining the position of primary care on this contentious issue.
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Affiliation(s)
- Diana Pasterfield
- Department of General Practice, North Wales Clinical School, Centre for Health Sciences Research, Cardiff University, Wrexham.
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Tynan A. Time to legalise assisted dying? Recruiting more vulnerable doctors may be the answer. BMJ 2005; 331:842; discussion 843. [PMID: 16210294 PMCID: PMC1246125 DOI: 10.1136/bmj.331.7520.842-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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