Attitudes of UK doctors towards euthanasia and physician-assisted suicide: a systematic literature review

Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium

INTRODUCTION

Previous research has explored euthanasia's ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap exists in understanding the comprehensive value-based perspectives of other professionals involved in both somatic and psychiatric euthanasia. This paper aims to analyze the interplay among legal, medical, and ethical factors to clarify how foundational values shape the ethical discourse surrounding euthanasia in both somatic and psychiatric contexts. It seeks to explore these dynamics among all healthcare professionals and volunteers in Belgium.

METHODS

Semi-structured interviews were conducted with 30 Dutch-speaking healthcare workers who had encountered patients requesting euthanasia for psychiatric conditions, in Belgium, from August 2019 to August 2020. Qualitative thematic analysis was applied to the interview transcripts.

FINDINGS

Participants identified three pivotal values and virtues: religious values, professional values, and fundamental medical values encompassing autonomy, beneficence, and non-maleficence, linked to compassion, quality care, and justice. These values interwove across four tiers: the patient, the patient's inner circle, the medical realm, and society at large. Irrespective of their euthanasia stance, participants generally displayed a blend of ethical values across these tiers. Their euthanasia perspective was primarily shaped by value interpretation, significance allocation to key components, and tier weighting. Explicit mention of varying ethical values, potentially indicating distinct stances in favor of or against euthanasia, was infrequent.

CONCLUSION

The study underscores ethical discourse's central role in navigating euthanasia's intricate landscape. Fostering inclusive dialogue, bridging diverse values, supports informed decision-making, nurturing justice, and empathy. Tailored end-of-life healthcare in psychiatry is essential, acknowledging all involved actors' needs. The study calls for interdisciplinary research to comprehensively grasp euthanasia's multifaceted dimensions, and guiding policy evolution. While contextualized in Belgium, the implications extend to the broader euthanasia discourse, suggesting avenues for further inquiry and cross-cultural exploration.

Euthanasia of animals - association with veterinarians' suicidal thoughts and attitudes towards assisted dying in humans: a nationwide cross-sectional survey (the NORVET study)

BACKGROUND

Veterinarians are an occupational group with an increased suicide risk. Euthanasing animals may influence both veterinarians' views on assisted dying in humans and their suicide risk. We investigated (I) attitudes towards assisted dying, (II) whether the field of work and the frequency of euthanasing animals were associated with positive attitudes towards human euthanasia, and (III) whether frequently euthanasing animals was associated with serious suicidal thoughts.

METHODS

We conducted a nationwide cross-sectional study among veterinarians in Norway (response rate: 75%). Logistic regression models were used to calculate the odds ratios for both positive attitudes towards human euthanasia and serious suicidal thoughts. The analyses were adjusted for socio-demographic and work-related factors.

RESULTS

Fifty-five percent of the veterinarians agreed that euthanasia should be permitted for humans with a fatal disease and short life expectancy. Working with companion animals was independently associated with positive attitudes towards human euthanasia (OR = 1.66 (95% CI: 1.23-2.23)), while veterinarians' frequency of euthanasing animals was not. Frequency of euthanasing animals was independently associated with serious suicidal thoughts, OR = 2.56 (95% CI: 1.35-4.87).

CONCLUSIONS

Veterinarians' attitudes towards assisted dying in humans did not differ from those of the general population. Veterinarians' frequency of euthanasing animals was not associated with positive attitudes towards euthanasia in humans. However, veterinarians working in companion animal practices were more likely to have positive attitudes towards euthanasia in humans. Moreover, euthanising animals five times or more a week was associated with serious suicidal thoughts. We need more research to infer about causality in these findings.

Medical Assistance in Dying in Neurology

An increasing number of jurisdictions have legalized medical assistance in dying (MAID) with significant variation in the procedures and eligibility criteria used. In the United States, MAID is available for persons with terminal illnesses but is frequently sought by persons with neurologic conditions. Persons with conditions that cause cognitive impairment, such as Alzheimer dementia, are often ineligible for MAID, as their illness is not considered terminal in its early stages, whereas in later stages, they may have impaired decision-making capacity.

Exploring caregivers' perceptions of community-based service requirements of patients with spinal cord injury: a qualitative study

BACKGROUND

The incidence of spinal cord injury is increasing worldwide. Patients with spinal cord injury and their families face many difficulties during the disease course. Caregivers are more involved with these patients than anyone else, so recognizing patients' care requirements based on caregivers' opinions can facilitate care provision to these people. The purpose of this study was to explore caregivers' perceptions of the community-based services requirements of patients with spinal cord injury.

METHODS

This qualitative research was conducted in Iran from Apr 2021 to Dec 2022 using the conventional content analysis method. The participants in the study included family caregivers and providers of home care services to patients with spinal cord injury, who were selected by purposeful sampling. Data were collected by conducting 14 face-to-face interviews and analyzed based on the method proposed by Lundman and Graneheim.

RESULTS

Data analysis led to the extraction of 815 primary codes, which were organized into two themes: community reintegration (with two categories, including the need to provide a suitable social platform and lifelong care) and palliative care (with two categories, including family conference and survival management).

CONCLUSION

Social facilities and infrastructure should be modified in a way that patients with spinal cord injury can appropriately benefit from community-based care services and an independent satisfactory life. Palliative care should be continuously provided from the time of lesion development until the patient's death.

Self-destruction or surrender? Religiosity and active versus passive euthanasia

Previous research suggests that people, especially religious people, are more opposed to active euthanasia, such as a lethal injection, than to passive euthanasia, such as withdrawing life support. The current research proposes a possible explanation for this finding-that active euthanasia is viewed as interfering with the natural course of life and death, but passive euthanasia is viewed as allowing it to take place. Two studies yielded results consistent with this hypothesis and found that how people think about the natural course of life and death substantially explained the greater opposition to active euthanasia among more religious people.

Media coverage of Belgium's first criminal case concerning euthanasia for psychiatric patients: A content analysis of Flemish newspapers and magazines

BACKGROUND

Belgium is one of the few countries worldwide where euthanasia on the grounds of unbearable suffering caused by a psychiatric disorder is legally possible. In April 2010 euthanasia was carried out on a 38-year-old Belgian woman with borderline personality disorder and/or autism. After a complaint by the family, three physicians were referred to the Court of Assizes on the charge of "murder by poisoning".

METHODS

A content analysis of print and online news coverage of the euthanasia case in a selected sample of Flemish newspapers and magazines, published between December 1, 2019 and March 1, 2020, was conducted to analyze the prominence and framing of the euthanasia case, as well as the portrayal of key figures in this case. A quantitative analysis, as well as an in-depth qualitative analysis (with the aid of NVivo 1.0 software) was performed.

RESULTS

One thousand two hundred fifteen news articles were identified through database searching. Of these, 789 articles were included after screening for relevance and eligibility. Mean prominence scores were moderate and did not statistically significantly differ between newspapers with a different historical ideological background or form (elite versus popular). The most frequent headline topics featured legal aspects (relating to the Belgian Euthanasia Law or the course of the trial). Headlines and content of most articles (90 and 89%, respectively) did not contain an essential standpoint on the euthanasia case itself or, if they did, were neutral. Historical ideological background, nor form of newspaper (elite versus popular) significantly influenced headline tone or article direction toward the euthanasia case. Despite this, our qualitative analysis showed some subtle differences in selection, statement or tonality of reports between certain newspapers with a different historical ideological background.

CONCLUSION

Although major Flemish newspapers and magazines generally were neutral in their coverage of the judicial case, major points of contention discussed were: the need for an evaluation and possible amendments to the existing Euthanasia Law, including a revision of the Belgian Control Commission and the system of penalties for physicians, and the absence of any consensus or guidance on how to define psychological suffering.

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

In 2017, Italy passed a law that provides for a systematic discipline on informed consent, advance directives, and advance care planning. It ranges from decisions contextual to clinical necessity through the tool of consent/refusal to decisions anticipating future events through the tools of shared care planning and advance directives. Nothing is said in the law regarding the issue of physician assisted suicide. Following the DJ Fabo case, the Italian Constitutional Court declared the constitutional illegitimacy of article 580 of the criminal code in the part in which it does not exclude the punishment of those who facilitate the suicide when the decision has been freely and autonomously made by a person kept alive by life-support treatments and suffering from an irreversible pathology, the source of physical or psychological suffering that he/she considers intolerable, but fully capable of making free and conscious decisions. Such conditions and methods of execution must be verified by a public structure of the national health service, after consulting the territorially competent ethics committee. This statement admits, within strict and regulated bounds, physician assisted suicide, so widening the range of end-of-life decisions for Italian patients. Future application and critical topics will be called into question by the Italian legislator.

Australian Health Professionals’ Attitudes toward Voluntary Assisted Dying: A Cross-Sectional Survey

Voluntary assisted dying (VAD) is when a terminally ill person with decision-making capacity consensually ends their life with assistance from an authorised professional. Many countries have legalised VAD, and health professionals’ roles within VAD frameworks are varied. Health professionals must be well informed of their legal obligations to ensure they practice within the legal boundaries, and those professionals with objections toward VAD should ensure that their eligible patients have equitable access. Given the current landscape of VAD, it is important to understand different health professionals’ attitudes toward VAD and what may underpin these attitudes. We explored (a) Australian health professionals’ attitudes toward VAD; (b) the psychological components that underpin those attitudes; (c) health professionals’ level of knowledge about VAD; (d) health professionals’ most common beliefs, emotions, and experiences related to VAD. A cross-sectional correlational survey design was used. A total of 182 Australian health professionals participated in the online survey based on a tripartite model of attitudes. We conducted a binomial logistic regression through a Generalised Linear Mixed Model and found polarised attitudes toward VAD between health professionals. Attitudes were accounted for by beliefs, emotions, education, and strength of religious beliefs. Knowledge of VAD was low, but not associated with overall attitude in our model. We highlight the importance of reflexive practice to help health professionals identify their values and feelings related to VAD, and to understand how these may affect their clinical practice. Low knowledge of VAD suggests that legislative and procedural training should be mandatory.

Perceptions of Patients and Their Families Regarding Limitation of Therapeutic Effort in the Intensive Care Unit

OBJECTIVE

Our objective was to determine and describe the opinion and attitudes of patients and their families regarding the limitation of therapeutic effort and advanced directives in critical patients and whether end-of-life planning occurs. Religious affiliation, education level, and pre-admission quality of life were also evaluated to determine whether they may influence decisions regarding appropriate therapeutic effort.

METHODS

A prospective, observational and descriptive study, approved by the center's ethical committee, was carried out with 257 participants (94 patients and 163 family members) in the intensive care unit (ICU). A questionnaire regarding the opinions of patients and relatives about situations of therapeutic appropriateness in case of poor prognosis or poor quality of life was used. The questionnaire had three sections. In the first section, sociodemographic features were investigated. In the second section, information was collected on the quality of life and functional situation before ICU admission (taking as a reference the situation one month before admission) assessed by the Karnofsky scale, Barthel index, and the PAEEC scale (Project for the Epidemiological Analysis of Critical Care Patients). The third section aimed to determine whether the family knew the patient's opinion regarding his/her end of life.

RESULTS

Of those interviewed, 62.2% would agree to limit treatment in case of poor prognosis or poor quality of future life. In contrast, 37.7% considered that they should fight for life, even if it is irretrievable. Only 1.6% had advanced directives registered, 43.9% of the participants admitted deterioration in their quality of life before ICU admission, 18.2% with moderate-severe deterioration. Our study shows that the higher the educational level, the lower the desire to fight for life when it is irretrievable and the greater the agreement to limit treatment. Besides, those participants not affiliated with a religion were significantly less likely to fight for life, including when irretrievable, than Catholics and were more likely to agree to limit treatment.

CONCLUSIONS

More than half of the participants would agree to limit treatment in the case of a poor prognosis. Our results indicate that patients do not prepare for the dying process well in advance. Religion and educational level were determining factors for the choice of procedures at the end of life, both for patients and their families.

The influence of religious/spiritual beliefs on Malaysian hospital healthcare workers’ attitudes towards suicide and suicidal patients: a qualitative study

Background

There has been mixed findings on whether a healthcare workers’ religious beliefs contribute positively or negatively to their attitudes towards suicidal patients.

Aims

This study aims to explore qualitatively the influence of religious/spiritual beliefs on healthcare workers’ attitudes towards suicide and suicidal patients in the culturally heterogeneous Malaysian population.

Methods

Thirty-one healthcare workers from diverse religious backgrounds, professions and medical disciplines were interviewed. Thematic analysis revealed the centrality of religion in determining healthcare workers’ acceptability of suicide, specific religious beliefs that influenced their views on the right-to-die issue, perceptions of the suicidal patient’s religiousness/spirituality, and the aspects and extent of religious relevance in professional philosophy and practice.

Results

Healthcare workers who could perceive the multifactorial nature of suicide causation had a more empathetic response. There were high levels of paternalism in the care of suicidal patients, involving unsolicited religious/spiritual advice practised as a form of suicide deterrent and social support.

Conclusions

The formal integration of religious/spiritual practices into the professional care of suicidal patients was indicated.

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

BACKGROUND

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

METHODS

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

RESULTS

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

Support for and willingness to be involved in voluntary assisted dying: A multisite, cross-sectional survey study of clinicians in Victoria, Australia

CONTEXT

In the Australian state of Victoria, specialist doctors are central to the operation of Voluntary Assisted Dying (VAD). However, a broad range of clinicians may be involved in the care of patients requesting or using VAD.

OBJECTIVES

To conduct a multisite, cross-sectional survey of clinicians in seven Victorian hospitals, to describe levels of support for and willingness to be involved in VAD and consider factors associated with clinician support for the VAD legislation and physicians' willingness to provide VAD in practice.

METHODS

All clinicians were invited to complete an online survey measuring demographic characteristics, awareness of and support for the VAD legislation, willingness to participate in VAD related activities, and reasons for willingness or unwillingness to participate in VAD.

RESULTS

Of 5690 who opened the survey, 5159 (90.1%) were included in the final sample and 73% (n=3768) supported the VAD legislation. The strongest predictor of support for the VAD legislation was clinical role. Forty percent (n=238) of medical specialists indicated they would be willing to participate in either the VAD consulting or coordinating role. Doctors did not differ in willingness between high impact (44%) and low impact specialty (41%), however, doctors specializing in palliative care or geriatric medicine were significantly less willing to participate (27%).

CONCLUSION

Approximately 73% of surveyed staff supported Victoria's VAD legislation. However, only a minority of medical specialists reported willingness to participate in VAD, suggesting potential access issues for patients requesting VAD in accordance with the legal requirements in Victoria. This article is protected by copyright. All rights reserved.

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

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

Factors Associated With University Students' Attitude Toward Euthanasia

Although euthanasia has been practiced for thousands of years, a wide controversy still exists around it. This study aimed to assess the attitude of university students toward euthanasia and its associated factors. The study included an online self-administered survey. Survey questions consisted of demographic information, psychological condition, and attitude toward euthanasia. A total of 1,188 students participated in the study. Approximately only one-third of the respondents (34.1%) viewed euthanasia as a moral practice, and just one-quarter (25.3%) supported legalizing it. The main reason for not supporting euthanasia was religious considerations (72.2%), followed by moral considerations (46.5%). Factors that predicted a positive attitude toward euthanasia (p < .05) included undefined religion, being male, feeling lonely, or having suicidal thoughts. Conclusively, the negative attitude toward euthanasia is primarily driven by religious beliefs. Furthermore, gender and psychological status play critical roles in students' attitudes toward euthanasia.

Medical Faculty Students' Views on Euthanasia: Does It Change With Medical Education?

OBJECTIVE

Euthanasia is the decision to terminate the lives of patients who do not improve with medical treatment at their explicit request. This study was carried out to determine the opinions of medical students regarding euthanasia and to evaluate the effect of medical education on this issue.

METHODS

This cross-sectional study was conducted among first and sixth-year students of the Gaziantep University School of Medicine during the 2018-2019 academic years.

RESULTS

Of the 242 students who participated in the study, 54.1% (131) were first-year and 45.9% (111) were sixth-year students. Overall, 39.7% of the first-year students and 31.5% of the sixth-year students supported active euthanasia. The percentage of students who were against passive euthanasia and physician-assisted suicide (PAS) was 63.4% and 53.4% for first-year students and 49.5% and 54.1% for sixth-year students, respectively.

CONCLUSION

Approximately half of the first and the sixth-year students were opposed to active euthanasia, passive euthanasia, and PAS, and there was no significant difference between these two groups of students in their being against euthanasia. However, there were significant differences between these two groups with respect to their reasons against euthanasia.

New Zealand medical students' views of euthanasia/assisted dying across different year levels

BACKGROUND

Previous studies report a majority of the general public support euthanasia/assisted dying (EAD), while a majority of doctors are opposed. In considering policy decisions about EAD, some may discount the views of doctors because they take them to be based on personal values or tradition, rather than reasons that the general public might share. One way to explore this notion is to examine whether medical students' views change during their medical education. The objective of this study was to learn how New Zealand medical students view EAD and whether students at different year levels have different views.

METHODS

An on-line survey of undergraduate medical students was conducted asking whether they supported a law change to allow EAD. Quantitative data was analysed using unadjusted and multiple logistic regression. Thematic analysis was conducted with the qualitative data.

RESULTS

A total of 326 students replied to the survey. The overall response rate was 28%. 65% of 2nd year students were supportive of EAD, compared to 39% in 5th year. The odds of 5th year students supporting a law change compared to 2nd year was 0.30 (95% CI: 0.15-0.60). The predominant themes found in the qualitative results indicate that medical students support or oppose EAD for reasons similar to those found in the wider debate, and that their views are influenced by a range of factors. However, several at all year levels cited an aspect of medical school as having influenced their views. This was mentioned by participants who were supportive of, opposed to, or unsure about EAD, but it was the type of influence most often mentioned by those who were opposed.

CONCLUSIONS

The quantitative findings show students at the end of 5th year were less likely to support EAD than students at the end of 2nd year. We suggest that this difference is most likely due to their time in medical education. This suggests that the lower support found among doctors is in part related to medical education and medical work rather than age, personality, or social context. The qualitative findings indicate that this is not related to a particular educational experience at Otago Medical School but a range.

UK Public's Views and Perceptions About the Legalisation of Assisted Dying and Assisted Suicide

Current debates about assisted dying and assisted suicide cover a series of medical, legal, moral, ethical and religious aspects. Yet, public views on the subject remain underexplored and, therefore, not always accounted for in the formation of public policy. This paper reports on empirical data from a cross-sectional study in the UK in 2019, which examines public views about the legalisation of assisted dying and assisted suicide, by means of a self-administered Qualtrics-based survey (self-devised vignettes). A combination of simple random and convenience sampling was used. Participants (n = 297) state their preference that both assisted dying and assisted suicide should be legalised in the UK (n = 70%), while doctors should be legally allowed to support such wishes of patients with an incurable and painful illness from which they will die (n = 62.22%). The paper concludes that public opinion needs to be further accounted for in policymaking and discourses regarding patient autonomy and dignity of care.

The Relationship of Palliative Care With Assisted Dying Where Assisted Dying is Lawful: A Systematic Scoping Review of the Literature

CONTEXT

A central approach of palliative care has been to provide holistic care for people who are dying, terminally ill, or facing life-limiting illnesses while neither hastening nor postponing death. Assisted dying laws allow eligible individuals to receive medically administered or self-administered medication from a health provider to end their life. The implementation of these laws in a growing number of jurisdictions therefore poses certain challenges for palliative care.

OBJECTIVES

To analyze the research literature about the relationship of assisted dying with palliative care, in countries where it is lawful.

METHODS

A five-stage scoping review process was adapted from the Joanna Briggs Institute. Data sources searched through October 2018 were MEDLINE, CINAHL, PsychINFO, SCOPUS, and ProQuest dissertations and theses, with additional material identified through hand searching. Research studies of any design were included, but editorials or opinion articles were excluded.

RESULTS

After reviewing 5778 references from searches, 105 were subject to full-text review. About 16 studies were included: from Belgium (n = 4), Canada (n = 1), Switzerland (n = 2), and the U.S. (n = 9). We found that the relationship between assisted dying and palliative care practices in these locations took varied and sometimes combined forms: supportive, neutral, coexisting, not mutually exclusive, integrated, synergistic, cooperative, collaborative, opposed, ambivalent, and conflicted.

CONCLUSION

The studies in this review cast only partial light on challenges faced by palliative care when assisted dying is legal. There is pressing need for more research on the involvement of palliative care in the developing practices of assisted dying, across a growing number of jurisdictions.

Continuing Professional Development for Primary Care Providers in Palliative and End-of-Life Care: A Systematic Review

Background and Objective: This review updates and expands on previous reviews of educational interventions for primary care providers (PCPs) involved in palliative and end-of-life care (PEoLC) and is the first to include early studies related to medical assistance in dying (MAiD). Methods: A comprehensive search strategy was conducted across five electronic databases to locate published interventional studies related to ongoing PEoLC and/or MAiD education for primary care professionals. A descriptive summary of results and a narrative discussion of common themes and comparisons are provided. Results: Thirty-seven studies met the inclusion criteria. The researchers found a myriad of interventions, including courses based, practical experience, mentoring, and workshops. The researchers categorized results by four domains: attitude, confidence, knowledge, and skills. Across domains, seven educational topics emerged: general care, interprofessional collaboration, nutrition, pain and symptom management, patient communication, and professional coping. Overall, studies employed various methodologies, but often relied on cross-sectionally measured self-assessment. Two articles were found that measured the impact of MAiD education. Conclusion: These findings suggest that PEoLC education can improve PCPs' perceived attitudes, confidence, knowledge, and skills across multiple areas of palliative care practice. While PCPs across studies valued educational interventions, the findings relating to the impact of PEoLC education on PCP's provision of effective PEoLC were unclear. However, most interventions resulted in enhanced confidence and knowledge. To date, there are only two studies that have examined MAiD educational programs. There is a need for studies of higher rigor with more emphasis on follow-up to clarify the impact training has on those involved in PEoLC and MAiD.

End-of-life decision making by Austrian physicians - a cross-sectional study

BACKGROUND

Austria has recently been embroiled in the complex debate on the legalization of measures to end life prematurely. Empirical data on end-of-life decisions made by Austrian physicians barely exists. This study is the first in Austria aimed at finding out how physicians generally approach and make end-of-life therapy decisions.

METHODS

The European end-of-life decisions (EURELD) questionnaire, translated and adapted by Schildmann et al., was used to conduct this cross-sectional postal survey. Questions on palliative care training, legal issues, and use of and satisfaction with palliative care were added. All Austrian specialists in hematology and oncology, a representative sample of doctors specialized in internal medicine, and a sample of general practitioners, were invited to participate in this anonymous postal survey.

RESULTS

Five hundred forty-eight questionnaires (response rate: 10.4%) were evaluated. 88.3% of participants had treated a patient who had died in the previous 12 months. 23% of respondents had an additional qualification in palliative medicine. The cause of death in 53.1% of patients was cancer, and 44.8% died at home. In 86.3% of cases, pain relief and / or symptom relief had been intensified. Further treatment had been withheld by 60.0%, and an existing treatment discontinued by 49.1% of respondents. In 5 cases, the respondents had prescribed, provided or administered a drug which had resulted in death. 51.3% of physicians said they would never carry out physician-assisted suicide (PAS), while 30.3% could imagine doing so under certain conditions. 38.5% of respondents supported the current prohibition of PAS, 23.9% opposed it, and 33.2% were undecided. 52.4% of physicians felt the legal situation with respect to measures to end life prematurely was ambiguous. An additional qualification in palliative medicine had no influence on measures taken, or attitudes towards PAS.

CONCLUSIONS

The majority of doctors perform symptom control in terminally ill patients. PAS is frequently requested but rarely carried out. Attending physicians felt the legal situation was ambiguous. Physicians should therefore receive training in current legislation relating to end-of-life choices and medical decisions. The data collected in this survey will help political decision-makers provide the necessary legal framework for end-of-life medical care.

Common dedication to facilitating good dying experiences: Qualitative study of end-of-life care professionals' attitudes towards voluntary assisted dying

BACKGROUND

Debate about appropriate and ethically acceptable end-of-life choices is ongoing, which includes discussion about the legalization of voluntary assisted dying. Given health professionals' role in caring for patients at the end life, their stance towards assisting a person with dying can have implications for policy development and implementation in jurisdictions where law changes are being considered.

AIM

To explore end-of-life care professionals' attitudes towards voluntary assisted dying 6 months prior to vote on legalization.

DESIGN

Qualitative study using textual data collected through semi-structured interviews. Purposive sampling strategy used to collect a broad representation of perspectives. Audio-recorded interviews were transcribed verbatim and subjected to qualitative descriptive analysis techniques.

PARTICIPANTS

A total of 16 health professionals with experience in caring for people with life-limiting illness.

RESULTS

Participants reported two overarching positions grounded in differing moral philosophies with compelling arguments both for and against legalization of voluntary assisted dying. A third and common line of argument emerged from areas of shared concern and uncertainty about the practical consequences of introducing voluntary assisted dying. While a diversity of opinion was evident, all participants advocated for more public education and funding into end-of-life care services to make high-quality care equitable and widely available.

CONCLUSION

Common dedication to reducing suffering and facilitating good dying experiences exists among experts despite their divergent views on voluntary assisted dying. Ongoing engagement with stakeholders is needed for practical resolution in the interest of developing health policy for best patient care.

Perceptions and intentions toward medical assistance in dying among Canadian medical students

Background

Medical assistance in dying (MAID) was legalized in Canada in 2016. As of July 2017, approximately 2149 patients have accessed MAID. There remains no national-level data on the perspectives of future physicians about MAID or its changing legal status. We provide evidence from a national survey of Canadian medical students about their opinions, intentions, and concerns about MAID.

Methods

From October 2016 to July 2017, we distributed an anonymous online survey to all students at 15 of Canada’s 17 medical schools. The survey collected data on respondent socio-demographic characteristics, features of their medical education, intentions for medical practice, and perspectives on MAID. We analyzed responses using univariate descriptive and stepwise multivariate logistic regression.

Results

In 1210 completed surveys, 71% of respondents reported being willing to provide MAID under a legal framework that permits it. Non-religious respondents reported greater willingness to participate in MAID than respondents of any religious affiliation (p < 0.001). Frequency of religious attendance was inversely associated with willingness to provide MAID (p < 0.001). Medical students born in Québec were more willing to provide MAID than respondents from other provinces (OR 2.21; p < 0.001). Age, sex, socioeconomic status, year of medical study, previous academic major, and rural/urban city of birth were not associated with willingness to provide MAID.

Conclusion

As the current class of medical students becomes the first cohort of new physicians to enter Canada’s changing medical and legal landscape around MAID, our findings inform the public debate by examining attributes associated with support or opposition to the practice.

Electronic supplementary material

The online version of this article (10.1186/s12910-019-0356-z) contains supplementary material, which is available to authorized users.

Truth-telling and doctor-assisted death as perceived by Israeli physicians

Background

Medicine has undergone substantial changes in the way medical dilemmas are being dealt with. Here we explore the attitude of Israeli physicians to two debatable dilemmas: disclosing the full truth to patients about a poor medical prognosis, and assisting terminally ill patients in ending their lives.

Methods

Attitudes towards medico-ethical dilemmas were examined through a nationwide online survey conducted among members of the Israeli Medical Association, yielding 2926 responses.

Results

Close to 60% of the respondents supported doctor-assisted death, while one third rejected it. Half of the respondents opposed disclosure of the full truth about a poor medical prognosis, and the others supported it. Support for truth-telling was higher among younger physicians, and support for doctor-assisted death was higher among females and among physicians practicing in hospitals. One quarter of respondents supported both truth-telling and assisted death, thereby exhibiting respect for patients’ autonomy. This approach characterizes younger doctors and is less frequent among general practitioners. Another quarter of the respondents rejected truth-telling, yet supported assisted death, thereby manifesting compassionate pragmatism. This was associated with medical education, being more frequent among doctors educated in Israel, than those educated abroad. All this suggests that both personal attributes and professional experience affect attitudes of physicians to ethical questions.

Conclusions

Examination of attitudes to two debatable medical dilemmas allowed portrayal of the multi-faceted medico-ethical scene in Israel. Moreover, this study, demonstrates that one can probe the ethical atmosphere of a given medical community, at various time points by using a few carefully selected questions.

Electronic supplementary material

The online version of this article (10.1186/s12910-019-0350-5) contains supplementary material, which is available to authorized users.

Representations of palliative care, euthanasia and assisted dying within advocacy declarations

It is well known that there are disagreements between the proponents of palliative care and of euthanasia or assisted dying, often with little common ground,shaping the end of life discourse internationally. Advocacy documents or 'declarations'constitute a significant feature of this discourse. The aim of this study was to explore the content of such declarations and to focus on what they can tell us about palliative care and assisted dying and their dispositions towards one another. 104 declarations were identified and included in the study, covering the period 1974 to 2017. These declarations were analysed following the principles of thematic content analysis. We classified them based on their primary purpose: those with the goal of advocating for palliative care services, education and research were grouped under 'palliative care declarations'; those with the primary objective of advocating for or against euthanasia/assisted dying were classified as "euthanasia/assisted dying declarations". Our analysis revealed that the content of the declarations could be broadly categorised into three dimensions: framing, claiming and demanding. We demonstrate that these declarations reveal a struggle over the construction of meanings relating to palliative care and assisted dying and constitute a valuable resource for the analysis of an unfolding debate.

Of dilemmas and tensions: a qualitative study of palliative care physicians' positions regarding voluntary active euthanasia in Quebec, Canada

OBJECTIVES

In 2015, the Province of Quebec, Canada passed a law that allowed voluntary active euthanasia (VAE). Palliative care stakeholders in Canada have been largely opposed to euthanasia, yet there is little research about their views. The research question guiding this study was the following: How do palliative care physicians in Quebec position themselves regarding the practice of VAE in the context of the new provincial legislation?

METHODS

We used interpretive description, an inductive methodology to answer research questions about clinical practice. A total of 18 palliative care physicians participated in semistructured interviews at two university-affiliated hospitals in Quebec.

RESULTS

Participants positioned themselves in opposition to euthanasia. Their justifications were framed within their professional commitment to not hasten death, which sat in tension with the value of patients' autonomy to choose how to die. Participants described VAE as unacceptable if it impeded opportunities to evaluate and alleviate suffering. Further, they contested government rhetoric that positioned VAE as a way to improve end-of-life care. Participants felt that VAE would diminish the potential of palliative care to relieve suffering. Dilemmas were apparent in their narratives, about reconciling respect for patient autonomy with broader palliative care values, and the value of accompanying and not abandoning patients who make requests for VAE while being committed to neither prolonging nor hastening death.

CONCLUSIONS

This study provides insight into nuanced positions of experienced palliative care physicians in Quebec and confirms expected tensions between an important stakeholder and the practice of VAE as guided by the new legislation.

Continuous Deep Sedation Until Death-a Swiss Death Certificate Study

BACKGROUND

In the last decade, the number of patients continuously deeply sedated until death increased up to fourfold. The reasons for this increase remain unclear.

OBJECTIVE

To identify socio-demographic and clinical characteristics of sedated patients, and concurrent possibly life-shortening medical end-of-life decisions.

DESIGN

Cross-sectional death certificate study in German-speaking Switzerland in 2001 and 2013.

PARTICIPANTS

Non-sudden and expected deaths (2001: N = 2281, 2013: N = 2256) based on a random sample of death certificates and followed by an anonymous survey on end-of-life practices among attending physicians.

MAIN MEASURES

Physicians' reported proportion of patients continuously deeply sedated until death, socio-demographic and clinical characteristics, and possibly life-shortening medical end-of life decisions.

KEY RESULTS

In 2013, physicians sedated four times more patients continuously until death (6.7% in 2001; 24.5.5% in 2013). Four out of five sedated patients died in hospitals, outside specialized palliative care units, or in nursing homes. Sedation was more likely among patients younger than 65 (odds ratio 2.24, 95% CI 1.6 to 3.2) and those dying in specialized palliative care (OR 2.2, 95% CI 1.3 to 3.8) or in hospitals (1.7, 95% CI 1.3 to 2.3). Forgoing life-prolonging treatment with the explicit intention to hasten or not to postpone death combined with intensified alleviation of symptoms was very strongly associated with continuous deep sedation (OR 6.8, 95% CI 4.7 to 9.8).

CONCLUSIONS

In Swiss clinical practice, continuously deeply sedated patients predominantly died outside specialized palliative care. The increasing trend over time appears to be related to changes in medical end-of-life practice rather than to patient's clinical characteristics.

Medical students and end-of-life decisions: the influence of religion

The objective of this study was to see if medical students' attitudes about medically assisted dying were influenced by their religious background and current beliefs. A cohort study was conducted using a self-completion study questionnaire in a large UK medical school. In total, 400 out of 505 questionnaires were completed (79%). The study population's characteristics are summarised as follows: mean age 22.7 years (range 18-44); 68.5% believe in god, 31.5% have no belief in god; religious background: Christian 45%, Hindu 16.5%, Muslim 22%, Other 10% and None 7%. The majority of students did not agree with euthanasia and physician-assisted suicide in the study scenario. Those who had a belief in god were more likely to disagree with actions that hasten death. The findings show this was particularly the case with students from a Muslim background. Gender was not related to overall agreement with actions that hasten death; being older, a finalist and a graduate were weakly associated with a greater likelihood of agreeing with such acts. This is an important issue which warrants further enquiry. The demographics of the UK medical population continue to shift, containing a higher proportion of people from Asia and with Asian British backgrounds than the general population. This study provides us with a basis for further exploration of the potential for disparity between the opinions of the UK population and those of medical workers and trainees, and how that might inform decisions about patient care at the end of life.

Physicians' views on current legislation around euthanasia and assisted suicide: Results of surveys commissioned by the Royal College of Physicians

Euthanasia and physician-assisted suicide have always been the subject of intense debate across society. In 2006 and in 2014, the Royal College of Physicians surveyed its members for their opinions on the subject. The results of these surveys are summarised here.

Euthanasia for people with psychiatric disorders or dementia in Belgium: analysis of officially reported cases

BACKGROUND

Euthanasia for people who are not terminally ill, such as those suffering from psychiatric disorders or dementia, is legal in Belgium under strict conditions but remains a controversial practice. As yet, the prevalence of euthanasia for people with psychiatric disorders or dementia has not been studied and little is known about the characteristics of the practice. This study aims to report on the trends in prevalence and number of euthanasia cases with a psychiatric disorder or dementia diagnosis in Belgium and demographic, clinical and decision-making characteristics of these cases.

METHODS

We analysed the anonymous databases of euthanasia cases reported to the Federal Control and Evaluation Committee Euthanasia from the implementation of the euthanasia law in Belgium in 2002 until the end of 2013. The databases we received provided the information on all euthanasia cases as registered by the Committee from the official registration forms. Only those with one or more psychiatric disorders or dementia and no physical disease were included in the analysis.

RESULTS

We identified 179 reported euthanasia cases with a psychiatric disorder or dementia as the sole diagnosis. These consisted of mood disorders (N = 83), dementia (N = 62), other psychiatric disorders (N = 22) and mood disorders accompanied by another psychiatric disorder (N = 12). The proportion of euthanasia cases with a psychiatric disorder or dementia diagnosis was 0.5% of all cases reported in the period 2002-2007, increasing from 2008 onwards to 3.0% of all cases reported in 2013. The increase in the absolute number of cases is particularly evident in cases with a mood disorder diagnosis. The majority of cases concerned women (58.1% in dementia to 77.1% in mood disorders). All cases were judged to have met the legal requirements by the Committee.

CONCLUSIONS

While euthanasia on the grounds of unbearable suffering caused by a psychiatric disorder or dementia remains a comparatively limited practice in Belgium, its prevalence has risen since 2008. If, as this study suggests, people with psychiatric conditions or dementia are increasingly seeking access to euthanasia, the development of practice guidelines is all the more desirable if physicians are to respond adequately to these highly delicate requests.

International Association for Hospice and Palliative Care Position Statement: Euthanasia and Physician-Assisted Suicide

BACKGROUND

Reports about regulations and laws on Euthanasia and Physician Assisted Suicide (PAS) are becoming increasingly common in the media. Many groups have expressed opposition to euthanasia and PAS while those in favor argue that severely chronically ill and debilitated patients have a right to control the timing and manner of their death. Others argue that both PAS and euthanasia are ethically legitimate in rare and exceptional cases. Given that these discussions as well as the new and proposed laws and regulations may have a powerful impact on patients, caregivers, and health care providers, the International Association for Hospice and Palliative Care (IAHPC) has prepared this statement.

PURPOSE

To describe the position of the IAHPC regarding Euthanasia and PAS.

METHOD

The IAHPC formed a working group (WG) of seven board members and two staff officers who volunteered to participate in this process. An online search was performed using the terms "position statement", "euthanasia" "assisted suicide" "PAS" to identify existing position statements from health professional organizations. Only statements from national or pan-national associations were included. Statements from seven general medical and nursing associations and statements from seven palliative care organizations were identified. A working document including a summary of the different position statements was prepared and based on these, an initial draft was prepared. Online discussions among the members of the WG took place for a period of three months. The differences were reconciled by email discussions. The resulting draft was shared with the full board. Additional comments and suggestions were incorporated. This document represents the final version approved by the IAHPC Board of Directors.

RESULT

IAHPC believes that no country or state should consider the legalization of euthanasia or PAS until it ensures universal access to palliative care services and to appropriate medications, including opioids for pain and dyspnea.

CONCLUSION

In countries and states where euthanasia and/or PAS are legal, IAHPC agrees that palliative care units should not be responsible for overseeing or administering these practices. The law or policies should include provisions so that any health professional who objects must be allowed to deny participating.

From Memory to Attitude: The Neurocognitive Process beyond Euthanasia Acceptance

Numerous questionnaire studies on attitudes towards euthanasia produced conflicting results, precluding any general conclusion. This might be due to the fact that human behavior can be influenced by automatically triggered attitudes, which represent ingrained associations in memory and cannot be assessed by standard questionnaires, but require indirect measures such as reaction times (RT) or electroencephalographic recording (EEG). Event related potentials (ERPs) of the EEG and RT during an affective priming task were assessed to investigate the impact of automatically triggered attitudes and were compared to results of an explicit questionnaire. Explicit attitudes were ambivalent. Reaction time data showed neither positive nor negative associations towards euthanasia. ERP analyses revealed an N400 priming effect with lower mean amplitudes when euthanasia was associated with negative words. The euthanasia-related modulation of the N400 component shows an integration of the euthanasia object in negatively valenced associative neural networks. The integration of all measures suggests a bottom-up process of attitude activation, where automatically triggered negative euthanasia-relevant associations can become more ambiguous with increasing time in order to regulate the bias arising from automatic processes. These data suggest that implicit measures may make an important contribution to the understanding of euthanasia-related attitudes.

When Physicians Report Having Used Medical Drugs to Deliberately End a Patient's Life: Findings of the "End-of-Life in France" Survey

CONTEXT

The debate on the decriminalization of active assistance in dying is still a topical issue in many countries where it is regarded as homicide. Despite the prohibition, some physicians say they have used drugs to intentionally end a patient's life.

OBJECTIVES

To provide some empirical grounding for the ongoing debate.

METHODS

Using data from the End-of-Life in France survey (a representative sample of 15,000 deaths that occurred in December 2009, questionnaires completed anonymously by the physicians who had certified the deaths), we selected all the cases where the physician had used one or more drugs to intentionally end a patient's life and compared the decisions and decision-making process with the conditions imposed by the French law for decisions to withhold or withdraw life-supporting treatments and by the Belgian law on euthanasia.

RESULTS

Of the 36 cases analyzed, four situations seemed to be deliberate acts after explicit requests from the patients, and only two seemed to fulfill the eligibility and due care conditions of the Belgian euthanasia law. Decisions made without any discussion with patients were quite common, and we observed inadequate labeling, frequent signs of ambivalence (artificial feeding and hydration not withdrawn, types of drug used), and little interprofessional consultation. Where the patient had requested euthanasia, the emotional burden on the physician was heavy.

CONCLUSION

These findings underscore the pressing need for a clarification of the concepts involved among health professionals, patients, and society at large, and better training and support for physicians.

Finnish physicians' attitudes towards active euthanasia have become more positive over the last 10 years

INTRODUCTION

Most physicians are against active euthanasia. Very little is known about the possible changes in the attitudes of physicians.

METHODS

A questionnaire was sent to a random sample of 1003 Finnish physicians of working age. A similar questionnaire had been sent to a random sample of Finnish physicians also in 1993 and 2003. The questionnaire consisted of statements about euthanasia, for which the participants were asked to express their agreement or disagreement on a 5-point Likert scale.

RESULTS

In general, Finnish physicians' attitudes towards active euthanasia have become considerably more positive. In 2003, 61% of the respondents were against the legalisation of euthanasia and 29% supported it. In 2013, both groups were of equal size (46%). The willingness to perform active euthanasia has not, however, increased significantly, even in a legalised setting.

CONCLUSIONS

The attitudes of Finnish physicians towards active euthanasia became considerably more positive between 2003 and 2013. There was no significant change, however, in the willingness to practice euthanasia if it became legal.

Physicians and euthanasia: a Canadian print-media discourse analysis of physician perspectives

BACKGROUND

Recent events in Canada have mobilized public debate concerning the controversial issue of euthanasia. Physicians represent an essential stakeholder group with respect to the ethics and practice of euthanasia. Further, their opinions can hold sway with the public, and their public views about this issue may further reflect back upon the medical profession itself.

METHODS

We conducted a discourse analysis of print media on physicians' perspectives about end-of-life care. Print media, in English and French, that appeared in Canadian newspapers from 2008 to 2012 were retrieved through a systematic database search. We analyzed the content of 285 articles either authored by a physician or directly referencing a physician's perspective.

RESULTS

We identified 3 predominant discourses about physicians' public views toward euthanasia: 1) contentions about integrating euthanasia within the basic mission of medicine, 2) assertions about whether euthanasia can be distinguished from other end-of-life medical practices and 3) palliative care advocacy.

INTERPRETATION

Our data showed that although some medical professional bodies appear to be supportive in the media of a movement toward the legalization of euthanasia, individual physicians are represented as mostly opposed. Professional physician organizations and the few physicians who have engaged with the media are de facto representing physicians in public contemporary debates on medical aid in dying, in general, and euthanasia, in particular. It is vital for physicians to be aware of this public debate, how they are being portrayed within it and its potential effects on impending changes to provincial and national policies.

Psychosocial determinants of physicians' intention to practice euthanasia in palliative care

BACKGROUND

Euthanasia remains controversial in Canada and an issue of debate among physicians. Most studies have explored the opinion of health professionals regarding its legalization, but have not investigated their intentions when faced with performing euthanasia. These studies are also considered atheoretical. The purposes of the present study were to fill this gap in the literature by identifying the psychosocial determinants of physicians' intention to practice euthanasia in palliative care and verifying whether respecting the patient's autonomy is important for physicians.

METHODS

A validated anonymous questionnaire based on an extended version of the Theory of Planned Behavior was mailed to a random sample of 445 physicians from the province of Quebec, Canada.

RESULTS

The response rate was 38.3% and the mean score for intention was 3.94 ± 2.17 (range: 1 to 7). The determinants of intention among physicians were: knowing patients' wishes (OR = 10.77; 95%CI: 1.33-86.88), perceived behavioral control-physicians' evaluation of their ability to adopt a given behavior-(OR = 4.35; 95%CI: 1.44-13.15), moral norm-the appropriateness of adopting a given behavior according to one's personal and moral values-(OR = 3.22; 95%CI: 1.29-8.00) and cognitive attitude-factual consequences of the adoption of a given behavior-(OR = 3.16; 95%CI: 1.20-8.35). This model correctly classified 98.8% of physicians. Specific beliefs that might discriminate physicians according to their level of intention were also identified. For instance, physicians' moral norm was related to the ethical principle of beneficence.

CONCLUSIONS

Overall, physicians have weak intentions to practice euthanasia in palliative care. Nevertheless, respecting patients' final wishes concerning euthanasia seems to be of particular importance to them and greatly affects their motivation to perform euthanasia.

Motivations of physicians and nurses to practice voluntary euthanasia: a systematic review

BACKGROUND

While a number of reviews have explored the attitude of health professionals toward euthanasia, none of them documented their motivations to practice euthanasia. The objective of the present systematic review was to identify physicians' and nurses' motives for having the intention or for performing an act of voluntary euthanasia and compare findings from countries where the practice is legalized to those where it is not.

METHODS

The following databases were investigated: MEDLINE/PubMed (1950+), PsycINFO (1806+), CINAHL (1982+), EMBASE (1974+) and FRANCIS (1984+). Proquest Dissertations and Theses (1861+) was also investigated for gray literature. Additional studies were included by checking the references of the articles included in the systematic review as well as by looking at our personal collection of articles on euthanasia.

RESULTS

This paper reviews a total of 27 empirical quantitative studies out of the 1 703 articles identified at the beginning. Five studies were in countries where euthanasia is legal and 22 in countries where it is not. Seventeen studies were targeting physicians, 9 targeted nurses and 1 both health professionals. Six studies identified the motivations underlying the intention to practice euthanasia, 16 the behavior itself and 5 both intention and behavior. The category of variables most consistently associated with euthanasia is psychological variables. All categories collapsed, the four variables most frequently associated with euthanasia are past behavior, medical specialty, whether the patient is depressed and the patient's life expectancy.

CONCLUSIONS

The present review suggests that physicians and nurses are motivated to practice voluntary euthanasia especially when they are familiar with the act of euthanasia, when the patient does not have depressive symptoms and has a short life expectancy and their motivation varies according to their medical specialty. Additional studies among nurses and in countries where euthanasia is legal are needed.

Decisions that hasten death: double effect and the experiences of physicians in Australia

BACKGROUND

In Australian end-of-life care, practicing euthanasia or physician-assisted suicide is illegal. Despite this, death hastening practices are common across medical settings. Practices can be clandestine or overt but in many instances physicians are forced to seek protection behind ambiguous medico-legal imperatives such as the Principle of Double Effect. Moreover, the way they conceptualise and experience such practices is inconsistent. To complement the available statistical data, the purpose of this study was to understand the reasoning behind how and why physicians in Australia will hasten death.

METHOD

A qualitative investigation was focused on palliative and critical/acute settings. A thematic analysis was conducted on semi-structured in-depth interviews with 13 specialist physicians. Attention was given to eliciting meanings and experiences in Australian end-of-life care.

RESULTS

Highlighting the importance of a multidimensional approach, physicians negotiated multiple influences when death was regarded as hastened. The way they understood and experienced end-of-life care practices were affected by politico-religious and cultural influences, medico-legal imperatives, and personal values and beliefs. Interpersonal and intrapsychic aspects further emphasised the emotional and psychological investment physicians have with patients and others. In most cases death occurred as a result of treating suffering, and sometimes to fulfil the wishes of patients and others who requested death. Experience was especially subject to the efficacy with which physicians negotiated complex but context-specific situations, and was reflective of how they considered a good death. Although many were compelled to draw on the Principle of Double Effect, every physician reported its inadequacy as a medico-legal guideline.

CONCLUSIONS

The Principle of Double Effect, as a simplistic and generalised guideline, was identified as a convenient mechanism to protect physicians who inadvertently or intentionally hastened death. But its narrow focus on the physician's intent illuminated how easily it may be manipulated, thus impairing transparency and a physician's capacity for honesty. It is suggested the concept of "force majeure" be examined for its applicability in Australian medical end-of-life law where, consistent with a multidimensional and complex world, a physician's motivations can also be understood in terms of the emotional and psychological pressures they face in situations that hasten death.

Physician aid-in-dying: cautionary words

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

A cross-sectional study of mental health in UK veterinary undergraduates

Wellbeing (positive mental health) and mental ill-health of veterinary students from a single UK school were quantified using validated psychological scales. Attitudes towards mental ill-health and suicide were also assessed. Results were compared with published data from the UK general population and veterinary profession. Of the total student population (N=1068), 509 (48 per cent) completed a questionnaire. Just over half (54 per cent) of the respondents had ever experienced mental ill-health, with the majority reporting a first occurrence before veterinary school. Student wellbeing was significantly poorer (p<0.0001) than general population estimates, but not significantly different (p=0.2) from veterinary profession estimates. Degree of mental distress in students was significantly higher than in the general population (p<0.0001). Despite the majority (94 per cent) agreeing that 'Anyone can suffer from mental health problems', students were significantly more likely than members of the general population to agree that 'If I were suffering from mental health problems, I wouldn't want people knowing about it' (p<0.0001). Students were more likely to have thought about suicide, but less likely to have made an attempt (p<0.001; p=0.005), than members of the general population. The possibility of non-response bias must be considered when interpreting findings. However, strong similarities between results from this study population and the UK veterinary profession, as well as other veterinary student populations internationally, suggest no substantial school-level bias.

Factors associated with the rejection of active euthanasia: a survey among the general public in Austria

BACKGROUND

In recent decades, the general public has become increasingly receptive toward a legislation that allows active voluntary euthanasia (AVE). The purpose of this study was to survey the current attitude towards AVE within the Austrian population and to identify explanatory factors in the areas of socio-demographics, personal experiences with care, and ideological orientation. A further objective was to examine differences depending on the type of problem formulation (abstract vs. situational) for the purpose of measuring attitude.

METHODS

A representative cross-sectional study was conducted across the Austrian population. Data were acquired from 1,000 individuals aged 16 years and over based on telephone interviews (CATI). For the purpose of measuring attitude toward AVE, two different problem formulations (abstract vs. situational) were juxtaposed.

RESULTS

The abstract question about active voluntary euthanasia was answered negatively by 28.8%, while 71.2% opted in favour of AVE or were undecided. Regression analyses showed rejection of AVE was positively correlated with number of adults and children in the household, experience with care of seriously ill persons, a conservative worldview, and level of education. Mean or high family income was associated with lower levels of rejection. No independent correlations were found for variables such as sex, age, political orientation, self-rated health, and experiences with care of terminally ill patients. Correlation for the situational problem formulation was weaker and included fewer predictors than for the abstract question.

CONCLUSIONS

Our results suggest that factors relating to an individual's interpersonal living situation and his/her cognitive convictions might be important determinants of the attitude toward AVE. If and to the extent that personal care experience plays a role, it is rather associated with rejection than with acceptance of AVE.

A comparison of attitudes toward euthanasia among medical students at two Polish universities

The aim of the study conducted upon completion of obligatory palliative medicine courses among 588 medical students at two universities was to compare their attitudes toward euthanasia. Four hundred ninety-two (84.97 %) students were Catholics; 69 (11.73 %) declared they would practice euthanasia, 303 (51.53 %) would not, and 216 students (36.73 %) were not sure. The idea of euthanasia legalisation was supported by 174 (29.59 %) respondents, opposed by 277 (47.11 %), and 137 (23.30 %) were undecided. Five hundred fifty-six (94.56 %) students did not change their attitudes toward euthanasia after palliative medicine courses. Students from the two universities were found to have different opinions on practicing euthanasia, euthanasia law and possible abuse which might follow euthanasia legalisation, but they shared similar views on the choice of euthanasia if they themselves were incurably ill and the legalisation of euthanasia. Gender and religion influenced students' answers. Differences observed between medical students at the two universities might be related to gender and cultural differences.

Combined qualitative and quantitative research designs

PURPOSE OF REVIEW

Mixed methods research designs have been recognized as important in addressing complexity and are recommended particularly in the development and evaluation of complex interventions. This article reports a review of studies in palliative care published between 2010 and March 2012 that combine qualitative and quantitative approaches.

RECENT FINDINGS

A synthesis of approaches to mixed methods research taken in 28 examples of published research studies of relevance to palliative and supportive care is provided, using a typology based on a classic categorization put forward in 1992.

SUMMARY

Mixed-method studies are becoming more frequently employed in palliative care research and resonate with the complexity of the palliative care endeavour. Undertaking mixed methods research requires a sophisticated understanding of the research process and recognition of some of the underlying complexities encountered when working with different traditions and perspectives on issues of: sampling, validity, reliability and rigour, different sources of data and different data collection and analysis techniques.

Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying

BACKGROUND

Assisted dying is legal in four European countries and three American states. Elsewhere, particularly in more affluent or mainly Protestant countries, it remains controversial. Dominant headlines feature professional (medical, legal, religious) arguments versus celebrity campaigners; ordinary people are less clearly represented.

AIM

To synthesise the international evidence of people's views and attitudes towards assisted dying in order to inform current debate about this controversial issue.

DESIGN

Systematic review and mixed method synthesis of qualitative and survey data.

DATA SOURCES

Eleven electronic databases from inception to October 2011; bibliographies of included studies.

REVIEW METHODS

Two reviewers independently screened papers and appraised quality. Qualitative results were extracted verbatim; survey results were summarised in a table. Qualitative data were synthesised using framework methods and survey results integrated where they supported, contrasted or added to the themes identified.

RESULTS

Sixteen qualitative studies and 94 surveys were included; many participants considered the immediate relevance of assisted dying for them. Themes related to poor quality of life, a good quality of death, potential abuse of assisted dying and the importance of individual stance. People valued autonomy in death as much as in life. Attitudes were diverse, complex and related to definitions of unbearable suffering including physical, psycho-social and existential factors and were consistent regardless of social, economic, legal and health-care contexts.

CONCLUSION

Our review sheds light on ordinary people's perspectives about assisted dying, when they are ill or disabled. Unbearable suffering is a key construct, and common factors are revealed that lead people to ask for help to die. The consistency of international views indicates a mandate for legislative and medical systems worldwide to listen and understand this.

Attitudes Toward Euthanasia Among Doctors in a Tertiary Care Hospital in South India: A Cross Sectional study

Context:

Advances in expertise and equipment have enabled the medical profession to exercise more control over the processes of life and death, creating a number of moral and ethical dilemmas. People may live for extended periods with chronic painful or debilitating conditions that may be incurable.

Aim:

This study attempts to study the attitudes of doctors toward euthanasia and the possible factors responsible for these attitudes.

Settings and Design:

A cross-sectional survey of 213 doctors working at a tertiary care hospital was conducted to determine their attitudes toward euthanasia.

Materials and Methods:

A self-administered questionnaire was used to assess attitudes and personal perceptions about euthanasia.

Statistical Analysis Used:

The Chi square test was used to assess factors influencing attitudes toward euthanasia.

Results:

A majority of the respondents (69.3%) supported the concept of euthanasia. Relief from unbearable pain and suffering was the most commonly (80.3%) cited reason for being willing to consider the option of euthanasia. Majority of those who were against euthanasia (66.2%) felt that the freedom to perform euthanasia could easily be misused. Disapproval of euthanasia was associated with religious affiliation (P<0.001) and speciality (P<0.001).

Conclusions:

A majority of the doctors in this study supported euthanasia for the relief of unbearable pain and suffering. Religion and speciality appear to be significant in determining attitudes toward euthanasia.

Assisted or hastened death: the healthcare practitioner's dilemma

Assisting or hastening death is a dilemma with many ethical as well as practical issues facing healthcare practitioners in most countries worldwide now. Various arguments for and against assisted dying have been made over time but the call from the public for the legalisation of euthanasia and assisted suicide has never been stronger. While some studies have documented the reluctance of medical and other healthcare professionals to be involved in the practice of assisted dying or euthanasia, there is still much open debate in the public domain. Those who have the most experience of palliative care are strongest in their opposition to hastening death. This paper explores salient practical and ethical considerations for healthcare practitioners associated with assisting death, including a focus on examining the concepts of autonomy for patients and healthcare practitioners. The role of the healthcare practitioner has clearly and undoubtedly changed over time with advances in healthcare practices but the duty of care has not changed. The dilemmas for healthcare practitioners thus who have competent patients requesting hastened death extends far beyond acting within a country’s laws as they go to the very heart of the relationship between the practitioner and patient.