Involvement of palliative care in euthanasia practice in a context of legalized euthanasia: A population-based mortality follow-back study

Maybe for unbearable suffering: Diverse racial, ethnic and cultural perspectives of assisted dying. A scoping review

BACKGROUND

Assisted dying, also commonly known as euthanasia and physician-assisted suicide, is legal in many countries. Interest in assisted dying is growing due to evolving societal understandings of a good death and a desire for choice. Ethico-legal perspectives are well-known, but as societies become more heterogenous, a greater understanding of the perspectives of people from diverse racial, ethnic, and cultural backgrounds is needed.

AIM

To explore perspectives of people from diverse racial, ethnic and cultural backgrounds about assisted dying.

DESIGN

Scoping review with narrative synthesis. The protocol was registered with Open Science Framework.

DATA SOURCES

Medline, CINAHL Complete, PsycINFO and ProQuest Dissertations & Theses Global were searched from inception to May 2023. Citations were independently assessed against inclusion and exclusion criteria.

RESULTS

Of the 17 included studies, perspectives of assisted dying were presented according to religion, religiosity, spirituality, race, ethnicity and ancestry. Perspectives were diverse, presenting more as a spectrum, with multiple intersections and interconnections. Support and/or opposition for assisted dying differed according to cultural attributes, but even amongst those with similar cultural attributes, perspectives differed according to life experiences and notions of suffering.

CONCLUSION

Perspectives on assisted dying are dynamic and evolving. Even where assisted dying is legalised, individual's cultural attributes contribute to unique perspectives of assisted dying as an end-of-life option. Thus, understanding a person's culture, beliefs, expectations and choices in illness, treatment goals and care is fundamental, extending beyond what may be already considered as part of clinician-patient care relationships and routine advance care planning.

Palliative Care against Medically Assisted Death? Misunderstanding and Instrumental Objections

CONTEXT

Palliative Care (PC) and Medically Assisted Death (MAD), specifically assisted suicide and euthanasia, are distinct practices characterized by differing objectives, methods, implementation and outcomes. Representatives of PC, including scientific societies or physicians, may, in certain cases, adopt a critical stance towards MAD.

OBJECTIVES

The study aims to explore the underlying reasons for such opposition.

METHODS

To this end, the philosophical underpinnings and legal conditions of PC and MAD will be analyzed.

RESULTS

The ethical and philosophical landscape of PC and MAD leads us to identify, on one hand, the Hippocratic paradigm and, on the other hand, what we call Socratic medicine. From a legal analysis perspective, the presence of intolerable suffering serves as a common ground between the two practices, albeit risking being the subject of misunderstandings and instrumental objections.

CONCLUSION

Preventing an instrumental use of PC in relation to MAD is crucial to enable the respect and the coexistence of the two practices.

"People aren't happy to see refugees coming to Switzerland. They don't like assisted suicide for foreigners": Organizations' perspectives regarding the right-to-die and suicide tourism

The practice of suicide tourism refers to the traveling of individuals to other countries to seek legally permitted assisted suicide. This study employed a descriptive qualitative research approach exploring how right-to-die organizations perceive suicide tourism and its implications on the right-to-die. Five themes emerged following the analysis of 12 in-depth interviews with activists from right-to-die organizations and 13 relevant documents: (1) unequivocal attitudes toward suicide tourism; (2) relationships between the organizations and the media; (3) acting to change the legal status of the right-to-die; (4) the role of the family in interactions between the organization and the person seeking assistance; and (5) reciprocal relations between the organizations and the physicians. The findings reveal ambivalent attitudes within such organizations toward suicide tourism, inherent tension among participating physicians, and complex relationships between assisted suicide, palliative care, and the physicians' duty to promote individual choice at end-of-life.

What medical conditions lead to a request for euthanasia? A rapid scoping review

Background and Aims

Euthanasia is a controversial issue related to the right to die. Although euthanasia is mostly requested by terminally sick individuals, even in societies where it is legal, it is unclear what medical conditions lead to euthanasia requests. In this scoping review, we aimed to compile medical conditions for which euthanasia has been requested or performed around the world.

Methods

The review was preferred reporting items for systematic reviews and meta-analysis for scoping reviews (PRISMA-ScR) checklist. Retrieved search results were screened and unrelated documents were excluded. Data on reasons for conducting or requesting euthanasia along with the study type, setting, and publication year were extracted from documents. Human development index and euthanasia legality were also extracted. Major medical fields were used to categorize reported reasons. Group discussions were conducted if needed for this categorization. An electronic search was undertaken in MEDLINE through PubMed for published documents covering the years January 2000 to September 2022.

Results

Out of 3323 records, a total of 197 papers were included. The most common medical conditions in euthanasia requests are cancer in a terminal phase (45.4%), Alzheimer's disease and dementia (19.8%), constant unbearable physical or mental suffering (19.8%), treatment-resistant mood disorders (12.2%), and advanced cardiovascular disorders (12.2%).

Conclusion

Reasons for euthanasia are mostly linked to chronic or terminal physical conditions. Psychiatric disorders also lead to a substantial proportion of euthanasia requests. This review can help to identify the features shared by conditions that lead to performing or requesting euthanasia.

Contemplating the Impacts of Canadian Healthcare Institutions That Refuse to Provide Medical Assistance in Dying: A Framework-Based Discussion of Potential Health Access Implications

INTRODUCTION

Following the historic Canadian legislation on medical assistance in dying (MAiD) in 2016, many implementation challenges and ethical quandaries have formed the focus of further scholarly investigation and policy revisions. Of these, conscientious objections held by some healthcare institutions have involved relatively less scrutiny, despite indicating possible hurdles to the universal availability of MAiD services in Canada.

METHODS

In this paper, we contemplate potential accessibility concerns that pertain specifically to service access, with the hope to trigger further systematic research and policy analysis on this frequently overlooked aspect of MAiD implementation. We organize our discussion using two important health access frameworks: Levesque and colleagues' Conceptual Framework for Access to Health and the Provisional Framework for MAiD System Information Needs (Canadian Institute for Health Information).

RESULTS

Our discussion is organized along five framework dimensions through which institutional non-participation may generate or exacerbate inequities in MAiD utilization. Considerable overlaps are revealed across framework domains, indicating the complexity of the problem and the need for further investigation.

CONCLUSION

Conscientious dissensions on the part of healthcare institutions form a likely barrier to ethical, equitable, and patient-oriented MAiD service provision. Comprehensive, systematic evidence is urgently needed to understand the nature and scope of resulting impacts. We urge Canadian healthcare professionals, policymakers, ethicists, and legislators to attend to this crucial issue in future research and in policy discussions.

Voluntary Assisted Dying/Euthanasia: Will This Have an Impact on Cancer Care in Future Years?

OPINION STATEMENT

In considering the impact of medically hastened death (MHD) on cancer care, a wide range of variables needs to be considered including demographic factors, diagnoses, local cultural factors, and the legislative frameworks in place. Here, we present a synthesis of recently available published literature and empirical data collected following legislative change to enable MHD in Victoria, Australia to explore in detail the potential impact of MHD on cancer care with a focus on patients/families and professional groups. Our findings reveal that for patients and families, both physical and existential distress frequently underlie MHD requests, with the latter less readily recognised by health professionals. The responses of those around the patient making the request may have a very significant impact on relationships within families and upon the nature of the subsequent bereavement. For palliative care, while differing views may remain, it appears that there has been some accommodation of MHD into or alongside practice over time. The recognition of a shared commitment to relief of suffering of palliative care and MHD appears a helpful means of establishing how these practices may co-exist. In cancer practice more broadly, as individual professionals reflect upon their own roles, new relationships and pathways of patient movement (or referral) must be established in response to patients' requests. Our findings also highlight many unanswered questions in understanding the impact of MHD, including that upon those dying who choose not to access MHD, First Nations peoples, the participating health professionals' longer term, and the relief of suffering itself. A systematic approach to the evaluation of MHD legislation must be adopted in order to understand its full impact. Only then could it be determined if the aspirations for such legislative change were being met.

Medical Assistance in Dying and Palliative Care: Shared Trajectories

Medical Assistance in Dying (MAID) and palliative care often have an antagonistic relationship in jurisdictions where both are legal, but the early ethical and legal history of palliative care closely mirrors that of MAID in important ways. Palliative practices that are commonplace today were considered homicide or "medically assisted death" in most jurisdictions until quite recently. Moreover, while many patients request MAID today for reasons that are criticized as "ableist," the same rationale is accepted without comment or judgment when used to justify withdrawal of life support or a discontinuation of life-prolonging therapies. Concerns about factors that undermine autonomous decisions for MAID would apply equally to routine palliative care practices. By the same token, palliative care exists because no field in medicine is able to fix every problem it encounters. It is ironic, therefore, that some palliative care providers oppose MAID with the hubristic argument that we can relieve all forms of suffering. Palliative care providers may choose not to participate in MAID, but palliative care and MAID do not have to be mutually exclusive and are often complementary and synergistic for patients and families.

Legalised active assistance in dying: palliative care stakeholders' national e-consultation

OBJECTIVES

There is a growing debate surrounding the legalisation of medical assistance in dying (MAID). MAID is currently prohibited by the French law; however, the debate has recently been reinvigorated in France. This study aims to collect opinions of palliative care stakeholders (PCS) regarding the legalisation of MAID and to identify the factors associated with their opinions.

METHODS

We performed a transversal survey between 26 June 2021 and 25 July 2021, on PCS who were on the French national scientific society for palliative care. Participants were invited by email.

RESULTS

1439 PCS took part and expressed an opinion about the legalisation of MAID. 1053 (69.7%) were against the legalisation of MAID. When forced to choose which option should be privileged if the law had to change, 3.7% favoured euthanasia, 10.1% favoured assisted suicide with provision of lethal drug by a professional, 27.5% favoured assisted suicide with prescription of a lethal drug and 29.5% favoured assisted suicide with provision of a lethal drug by an association. The opinion regarding legalisation of MAID was statistically different depending on the participant profession (p<0.001) and when comparing clinical and non-clinical positions (p<0.001). A quarter of participants (26.7%) believe that legalising MAID might lead them to change their current position.

CONCLUSIONS

Overall, French palliative care professionals are against a modification of the current legal framework for legalising MAID but some might change their current position if a law was voted. This might destabilise the PCS demography that is already worrying.

Attitudes and Behaviors of Palliative Care Nurses on Euthanasia

This review was planned to present an overview of the findings in the scientific literature on euthanasia, palliative care, and nurses' attitudes and behaviors. A literature search was done in "EBSCO," "PubMed" databases, and "Google Scholar" search engines. In the study, a search was made between January and March 2023 using the keywords "palliative care," "euthanasia," and "nurse attitudes." Articles published in English and accessible were included in the research. Palliative care practices differ according to the health system, socioeconomic status, cultural conditions, geographical location, and education levels of countries On the other hand, discussions on the integration of euthanasia into palliative care practices continue. While palliative care practices differentiate in countries where euthanasia has been legalized, scientific, legal, religious, and ethical discussions continue in countries where euthanasia is not legal. There are many different variables, such as age, gender, professional experience, and cultural and religious factors, that affect nurses' attitudes and behaviors on this issue. It can be suggested that the results of the research, which will evaluate the factors affecting the attitudes of nurses toward euthanasia, death and terminally ill patients, include social changes in order to provide a literature and database in this field.

“Respecting our patients’ choices”: making the organizational decision to participate in voluntary assisted dying provision: findings from semi-structured interviews with a rural community hospice board of management

Background

There is limited literature around how palliative care organizations determine the degree to which they will interface with voluntary assisted dying in jurisdictions where it is legal. The aim of this research was to describe the experience of the board of management of an Australian community-based hospice during their decision-making process around whether to support voluntary assisted dying in the facility, prior to the legislation coming into operation.

Methods

The Board considered this decision over ten meetings in 2020, during which time they received information on the legislation, relevant literature, feedback from workshops which included the community, comment from hospice founders, staff survey results and presentations by clinicians able to discuss the impact of voluntary assisted dying on palliative care services. Members were encouraged to make notes of their own experiences during this time. Following this, semi-structured interviews were conducted with seven of the nine board members. Interviews were audio-recorded and transcribed verbatim and analysed using conventional qualitative content analysis method.

Results

The board members experienced a sense of journey in reaching an overall decision, which was to allow full participation in voluntary assisted dying provision for inpatients. Themes based on the journey motif included: starting from a personal view; moving to a hospice perspective; exploring if voluntary assisted dying can be part of end-of-life care; awareness and assessment of risks to the Hospice; arriving at a common platform to vote on; factors facilitating a safe decision-making journey; and personal impact of the journey.

Conclusions

The group highlighted several facilitators of a successful outcome including having adequate time, the availability of useful resources, sound board processes and a trusting culture. The study may provide support to other healthcare organisations as they face similar decisions triggered by legislative change.

Medical assistance in dying in hospice: A qualitative study

OBJECTIVES

The modern hospice movement has historically opposed assisted dying. The 2016 legalisation of medical assistance in dying (MAID) in Canada has created a new reality for Canadian hospices. There have been few studies examining how the legalisation of MAID has affected Canadian hospices. Our objective was to identify the challenges and opportunities hospice workers think MAID brings to a hospice.

METHODS

This qualitative descriptive study included four focus groups and four semistructured interviews with Canadian hospice workers at two hospices, one which allowed MAID on site, and one which did not. Thematic analysis was used to understand and report these challenges and opportunities.

RESULTS

We constructed five themes. These themes detailed participants' beliefs in the abilities of hospice care, and how they felt MAID challenged these abilities. Further, participants felt that MAID itself created challenging situations for patients and families, and that local policies and practices led to additional institutional challenges. Some participants also felt that allowing MAID in hospice provided opportunities for more extensive end-of-life options.

CONCLUSIONS

The legalisation of MAID in Canada has created both challenges and opportunities for Canadian hospices. A balancing of these challenges and opportunities may provide a path for Canadian hospices to navigate their new reality. Increasing demand for MAID means that hospices are likely to continue to encounter requests for MAID, and should enact supports to ensure staff are able to manage these challenges and make best use of the opportunities.

Understanding why patients request euthanasia when it is illegal: a qualitative study in palliative care units on the personal and practical impact of euthanasia requests

Context

Some patients in palliative care units request euthanasia regardless of legislation. Although studies have explored the reasons for these requests, little is known about the subjective, relational, and contextual repercussions for the patient.

Objectives

The aim of this study is to understand the purpose of euthanasia requests from the patient's viewpoint and their personal and practical impact.

Methods

We conducted in-depth interviews with patients requesting euthanasia, their family members, and health care providers in 11 French palliative care units. A thematic analysis of the data was performed.

Results

In total, 18 patients were interviewed within 48 h of the request being made; 1 week later, 9 patients were interviewed again. Five main themes emerged: assuming the possibility of transgressing the forbidden, a call for unbearable suffering to be recognized, encouragement to change clinical practice, reclaiming a sense of freedom over medical constraints, and imagining a desirable future for oneself.

Conclusions

A request for euthanasia appears to be a willful means to remove oneself from the impasse of an existence paralyzed by suffering. It creates a space for discussion, which promotes negotiation with patients on care practices and therapeutics, and strengthens patients' sense of autonomy. Investigating the relationship between the evolution of euthanasia requests within the palliative care setting could be beneficial. It is important to encourage health care professionals to adopt a readiness to listen by interacting with patients in a way that is not momentarily action-oriented but rather focused on proactive discussion.

Reporting of Palliative Sedation and Use of Opioids at the End of Life in a Belgian University Hospital: A Pilot Study

Background: Palliative sedation requires no formal registration in Belgium. For euthanasia, however, there are clear guidelines in certain countries, including mandatory registration and evaluation of cases. Official guidelines have been developed for palliative sedation, but research still shows unskilled use of sedation and unclear demarcation between palliative sedation and euthanasia. Registration could be used to avoid unskilled use of sedation and to avoid use or abuse of sedation to hasten the patient's death (described as "slow/passive euthanasia"). Objective: To evaluate the current practice of palliative sedation and use of opioids and sedatives at the end of life by using a registration document. Design: Retrospective observational study. Setting/Subjects: We included all in-hospital deaths at an academic hospital in Belgium of patients (age ≥18 years) who had received parenteral opioids, benzodiazepines, barbiturates, or other anesthetics during the last 24 hours. Measurements: We investigated indications for palliative sedation, patients' and physicians' characteristics, types of medication used, and the decision-making process with the patients and family. The questionnaires were collected between July 9 and November 25, 2016. The study was approved by the Biomedical Ethics Committee of UZ Brussel (B.U.N. 1432016293). Results: In a population of 124 patients, refractory symptoms were reported in 94.4%. All patients received parenteral opioids (intravenously). Benzodiazepines were used in 51.6%. In 75.8%, physicians reported no change in treatment plan during end of life. Hastening death by increasing analgesics and/or sedatives was mentioned in 19.3%. The treatment plan was discussed with patients in 26.6% of cases. In 6 cases, an explicit intention to hasten death was mentioned; in 36 cases, doses of opioids/sedatives may not have been strictly proportional to symptoms. Conclusion: This Belgian study shows that objective reporting of palliative sedation can be used as a tool to ensure good clinical practice where patients receive the most appropriate end-of-life care, avoiding abusive and injudicious or unskilled use of sedation.

Navigating medical assistance in dying from Bill C-14 to Bill C-7: a qualitative study

Background

Even as healthcare providers and systems were settling into the processes required for Medical Assistance in Dying (MAID) under Bill C-14, new legislation was introduced (Bill C-7) that extended assisted death to persons whose natural death is not reasonably foreseeable. The purpose of this paper is to describe the experiences of nurses and nurse practitioners with the implementation and ongoing development of this transition.

Methods

This qualitative longitudinal descriptive study gathered data through semi-structured telephone interviews with nurses from across Canada; cross sectional data from 2020 to 2021 is reported here. The study received ethical approval and all participants provided written consent.

Findings

Participants included nurses (n = 34) and nurse practitioners (n = 16) with significant experience with MAID. Participants described how MAID had transitioned from a new, secretive, and anxiety-producing procedure to one that was increasingly visible and normalized, although this normalization did not necessarily mitigate the emotional impact. MAID was becoming more accessible, and participants were learning to trust the process. However, the work was becoming increasingly complex, labour intensive, and often poorly remunerated. Although many participants described a degree of integration between MAID and palliative care services, there remained ongoing tensions around equitable access to both. Participants described an evolving gestalt of determining persons’ eligibility for MAID that required a high degree of clinical judgement. Deeming someone ineligible was intensely stressful for all involved and so participants had learned to be resourceful in avoiding this possibility. The required 10-day waiting period was difficult emotionally, particularly if persons worried about losing capacity to give final consent. The implementation of C-7 was perceived to be particularly challenging due to the nature of the population that would seek MAID and the resultant complexity of trying to address the origins of their suffering within a resource-strapped system.

Conclusions

Significant social and system calibration must occur to accommodate assisted death as an end-of-life option. The transition to offering MAID for those whose natural death is not reasonably foreseeable will require intensive navigation of a sometimes siloed and inaccessible system. High quality MAID care should be both relational and dialogical and those who provide such care require expert communication skills and knowledge of the healthcare system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07222-5.

Social determinants of health and slippery slopes in assisted dying debates: lessons from Canada

The question of whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying has recently come to the fore in debates about the legalisation of assisted dying. For example, it was central to critiques of the 2021 amendments made to Canada's assisted dying law. The question of whether changes to a country's assisted dying legislation lead to descents down slippery slopes has also come to the fore-as it does any time a jurisdiction changes its laws. We explore these two questions through the lens of Canada's experience both to inform Canada's ongoing discussions and because other countries will confront the same questions if they contemplate changing their assisted dying law. Canada's Medical Assistance in Dying (MAiD) law has evolved through a journey from the courts to Parliament, back to the courts, and then back to Parliament. Along this journey the eligibility criteria, the procedural safeguards, and the monitoring regime have changed. In this article, we focus on the eligibility criteria. First, we explain the evolution of the law and what the eligibility criteria were at the various stops along the way. We then explore the ethical justifications for Canada's new criteria by looking at two elements of the often-corrosive debate. First, we ask whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying of decisionally capable people with mental illnesses and people with disabilities as their sole underlying medical conditions. Second, we ask whether Canada's journey supports slippery slope arguments against permitting assisted dying.

"I Am Okay With It, But I Am Not Going to Do It": The Exogenous Factors Influencing Non-Participation in Medical Assistance in Dying

Medical assistance in dying (MAID) processes are complex, shaped by legislated directives, and influenced by the discourse regarding its emergence as an end-of-life care option. Physicians and nurse practitioners (NPs) are essential in determining the patient's eligibility and conducting MAID provisions. This research explored the exogenous factors influencing physicians' and NPs' non-participation in formal MAID processes. Using an interpretive description methodology, we interviewed 17 physicians and 18 NPs in Saskatchewan, Canada, who identified as non-participators in MAID. The non-participation factors were related to (a) the health care system they work within, (b) the communities where they live, (c) their current practice context, (d) how their participation choices were visible to others, (e) the risks of participation to themselves and others, (f) time factors, (g) the impact of participation on the patient's family, and (h) patient-HCP relationship, and contextual factors. Practice considerations to support the evolving social contact of care were identified.

How does Medical Assistance in Dying affect end-of-life care planning discussions? Experiences of Canadian multidisciplinary palliative care providers

Background

More than a dozen countries have now legalized some form of assisted dying, and additional jurisdictions are considering similar legislations or expanding eligibility criteria. Despite the persistent controversies about the relationship between medicine, palliative care, and assisted dying, many people are interested in assisted dying. Understanding how end-of-life care discussions between patients and specialist palliative care providers may be affected by such legislation can inform end-of-life care delivery in the evolving socio-cultural and legal environment.

Aim

To explore how the Canadian Medical Assistance in Dying legislation affects end-of-life care discussions between patients and multidisciplinary specialist palliative care providers.

Design

Qualitative thematic analysis of semi-structured interviews.

Participants

Forty-eight specialist palliative care providers from Vancouver (n = 26) and Toronto (n = 22) were interviewed in person or by phone. Participants included physicians (n = 22), nurses (n = 15), social workers (n = 7), and allied health professionals (n = 4).

Results

Qualitative thematic analysis identified five notable considerations associated with Medical Assistance in Dying affecting end-of-life care discussions: (1) concerns over having proactive conversations about the desire to hasten death, (2) uncertainties regarding wish-to-die statements, (3) conversation complexities around procedural matters, (4) shifting discussions about suffering and quality of life, and (5) the need and challenges of promoting open-ended discussions.

Conclusion

Medical Assistance in Dying challenges end-of-life care discussions and requires education and support for all concerned to enable compassionate health professional communication. It remains essential to address psychosocial and existential suffering in medicine, but also to provide timely palliative care to ensure suffering is addressed before it is deemed irremediable. Hence, clarification is required regarding assisted dying as an intervention of last resort. Furthermore, professional and institutional guidance needs to better support palliative care providers in maintaining their holistic standard of care.

Trends and Patterns in the Public Awareness of Palliative Care, Euthanasia, and End-of-Life Decisions in 3 Central European Countries Using Big Data Analysis From Google: Retrospective Analysis

Background

End-of-life decisions, specifically the provision of euthanasia and assisted suicide services, challenge traditional medical and ethical principles. Austria and Germany have decided to liberalize their laws restricting assisted suicide, thus reigniting the debate about a meaningful framework in which the practice should be embedded. Evidence of the relevance of assisted suicide and euthanasia for the general population in Germany and Austria is limited.

Objective

The aim of this study is to examine whether the public awareness documented by search activities in the most frequently used search engine, Google, on the topics of palliative care, euthanasia, and advance health care directives changed with the implementation of palliative care services and new governmental regulations concerning end-of-life decisions.

Methods

We searched for policies, laws, and regulations promulgated or amended in Austria, Germany, and Switzerland between 2004 and 2020 and extracted data on the search volume for each search term topic from Google Trends as a surrogate of public awareness and interest. Annual averages were analyzed using the Joinpoint Regression Program.

Results

Important policy changes yielded significant changes in search trends for the investigated topics. The enactment of laws regulating advance health care directives coincided with a significant drop in the volume of searches for the topic of euthanasia in all 3 countries (Austria: −24.48%, P=.02; Germany: −14.95%, P<.001; Switzerland: −11.75%, P=.049). Interest in palliative care increased with the availability of care services and the implementation of laws and policies to promote palliative care (Austria: 22.69%, P=.01; Germany: 14.39, P<.001; Switzerland: 17.59%, P<.001). The search trends for advance health care directives showed mixed results. While interest remained steady in Austria within the study period, it increased by 3.66% (P<.001) in Switzerland and decreased by 2.85% (P<.001) in Germany.

Conclusions

Our results demonstrate that legal measures securing patients’ autonomy at the end of life may lower the search activities for topics related to euthanasia and assisted suicide. Palliative care may be a meaningful way to raise awareness of the different options for end-of-life care and to guide patients in their decision-making process regarding the same.

The ongoing discussion on termination of life on request. A review from a German/European perspective

BACKGROUND

Interest in the topic of termination of life has been growing for 2 decades. After legalisation of active euthanasia and assisted suicide (EAS) in the Netherlands in 2002, movements to implement similar laws started in other European countries. However, many people objected to legalisation on the basis of the experiences in the Netherlands and as a matter of principal.

METHODS

This selected and focussed review presents the theoretical discussions about EAS and describes the respective parliamentary discussions in Germany and the data and experiences in the Netherlands. It also considers people with mental disorders in the context of termination-of-life services.

RESULTS

So far, only a few European countries have introduced legislation on EAS. Legalisation of EAS in the Netherlands resulted in an unexpectedly large increase in cases. The number of people with mental disorders who terminate their lives on request remains low.

CONCLUSIONS

Experience from the Netherlands shows that widening criteria for EAS has problematic consequences.KEY POINTSTermination of life on request, which a subgroup of people support, is a matter of ongoing debate.Because of several problematic aspects, including ethical considerations, only a few countries in the world allow active euthanasia or assisted suicide.Even if euthanasia is well regulated, legalising it can have problematic consequences that are difficult to control, such as an unwanted excessive increase in euthanasia cases.The well-documented experiences with the euthanasia law in the Netherlands serve as an example of what is to be expected when euthanasia is legalised.We need to pay close attention to the relationship between suicide and suicide prevention on the one hand and euthanasia acts and promotion of euthanasia on the other.Further ethical, psychological and legal research is needed. In particular, the role of palliative medicine in societies' approach to end-of-life care must be explored in much more detail.

Challenges of implementing voluntary assisted dying in Victoria, Australia

Background:

Staff working in community palliative care services are accustomed to the intimate conversations that a patient being at home can engender. Being at home can provide a safe space for a patient to express difficulties, including expressing a desire for hastened death. With the implementation of voluntary assisted dying in Victoria in mid-2019, palliative care services have needed to review and adapt policies and practices to incorporate this new procedure. While it was anticipated that a small percentage of people would request access to voluntary assisted dying, in the wake of such significant change, there were numerous implications for palliative care services to consider. This paper describes both the organisational and individual changes undertaken by one community-based palliative care service, in anticipation of legalised assistance in dying. The range of responses to the issues raised are discussed, in preparation for, and in the early days of, voluntary assisted dying.

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.

The rocks and hard places of MAiD: a qualitative study of nursing practice in the context of legislated assisted death

Background

Medical Assistance in Dying (MAiD) was legalized in Canada in June, 2016. The Canadian government's decision to legislate assisted dying, an approach that requires a high degree of obligation, precision, and delegation, has resulted in unique challenges for health care and for nursing practice. The purpose of this study was to better understand the implications of a legislated approach to assisted death for nurses' experiences and nursing practice.

Methods

The study used a qualitative approach guided by Interpretive Description. Semi-structured interviews were conducted with 59 registered nurses and nurse practitioners. Interviews were audio-recorded, transcribed, and managed using qualitative analysis software. Analysis followed a procedure of data immersion, open coding, constant comparative analysis, and the construction of a thematic and interpretive account.

Results

Nurses in this study described great variability in how MAiD had been enacted in their work context and the practice supports available to guide their practice. The development of systems to support MAiD, or lack thereof, was largely driven by persons in influential leadership positions. Workplaces that supported a range of nurses' moral responses to MAiD were most effective in supporting nurses' well-being during this impactful change in practice. Participants cited the importance of teamwork in providing high quality MAiD-related care; although, many worked without the benefit of a team. Nursing work related to MAiD was highly complex, largely because of the need for patient-centered care in systems that were not always organized to support such care. In the absence of adequate practice supports, some nurses were choosing to limit their involvement in MAiD.

Conclusions

Data obtained in this study suggested that some workplace contexts still lack the necessary supports for nurses to confidently meet the precision required of a legislated approach to MAiD. Without accessible palliative care, sufficient providers, a supportive team, practice supports, and a context that allowed nurses to have a range of responses to MAiD, nurses felt they were legally and morally at risk. Nurses seeking to provide the compassionate care consistent with such a momentous moment in patients' lives, without suitable supports, find themselves caught between the proverbial rock and hard place.

Are We Evolving Toward Greater and Earlier Use of Palliative Home Care Support? A Trend Analysis Using Population-Level Data From 2010 to 2015

CONTEXT

The need for increased use and earlier initiation of palliative home care has been advocated by several international organizations.

OBJECTIVES

To investigate time trends in the use and timing of initiating palliative home care support (PHCS).

METHODS

We conducted an observational study using routinely collected population-level databases linked with health claims data for the entire population living at home that died of diseases indicative of palliative care needs in Belgium between 2010 and 2015 (n = 230,704). Trends and trends by cause of death and age were measured through changes over time in prevalence of use of PHCS. Rates were standardized for age, sex, and cause of death distribution in 2010. The median number of days before death when PHCS was initiated was calculated for each year.

RESULTS

Uptake of PHCS increased from 31.7% to 34.9% between 2010 and 2015. Trends were similar in size for all groups, except for people who died of dementia (smallest increase with 1.9 percent point). The timing of initiating PHCS advanced from 41 to 46 days before death, with the smallest increase observed among people who died of dementia (+2.5 days). The proportion of people receiving PHCS only in the last week of life changed from 15.3% to 13.9%.

CONCLUSION

This population-level study found a slight trend toward more and earlier initiation of PHCS between 2010 and 2015. However, uptake of PHCS remained below estimated needs in the population and the proportion of people receiving PHCS in their very late life remained stable over time.

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.

Factors associated with requesting and receiving euthanasia: a nationwide mortality follow-back study with a focus on patients with psychiatric disorders, dementia, or an accumulation of health problems related to old age

BACKGROUND

Recently, euthanasia and assisted suicide (EAS) in patients with psychiatric disorders, dementia, or an accumulation of health problems has taken a prominent place in the public debate. However, limited is known about this practice. The purpose of this study was threefold: to estimate the frequency of requesting and receiving EAS among people with (also) a psychiatric disorder, dementia, or an accumulation of health problems; to explore reasons for physicians to grant or refuse a request; and to describe differences in characteristics, including the presence of psychiatric disorders, dementia, and accumulation of health problems, between patients who did and did not request EAS and between patients whose request was or was not granted.

METHODS

A nationwide cross-sectional survey study was performed. A stratified sample of death certificates of patients who died between 1 August and 1 December 2015 was drawn from the central death registry of Statistics Netherlands. Questionnaires were sent to the certifying physician (n = 9351, response 78%). Only deceased patients aged ≥ 17 years and who died a non-sudden death were included in the analyses (n = 5361).

RESULTS

The frequency of euthanasia requests among deceased people who died non-suddenly and with (also) a psychiatric disorder (11.4%), dementia (2.1%), or an accumulation of health problems (8.0%) varied. Factors positively associated with requesting euthanasia were age (< 80 years), ethnicity (Dutch/Western), cause of death (cancer), attending physician (general practitioner), and involvement of a pain specialist or psychiatrist. Cause of death (neurological disorders, another cause) and attending physician (general practitioner) were also positively associated with receiving euthanasia. Psychiatric disorders, dementia, and/or an accumulation of health problems were negatively associated with both requesting and receiving euthanasia.

CONCLUSIONS

EAS in deceased patients with psychiatric disorders, dementia, and/or an accumulation of health problems is relatively rare. Partly, this can be explained by the belief that the due care criteria cannot be met. Another explanation is that patients with these conditions are less likely to request EAS.

Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations

BACKGROUND

Medical aid in dying (MAiD) was introduced in Quebec in 2015. Quebec clinical guidelines recommend that MAiD be approached as a last resort when other care options are insufficient; however, the law sets no such requirement. To date, little is known about when and how requests for MAiD are situated in the broader context of decision-making in end-of-life care; the timing of MAiD raises potential ethical issues.

METHODS

A retrospective chart review of all MAiD requests between December 2015 and June 2017 at two Quebec hospitals and one long-term care centre was conducted to explore the relationship between routine end-of-life care practices and the timing of MAiD requests.

RESULTS

Of 80 patients requesting MAiD, 54% (43) received the intervention. The median number of days between the request for MAiD and the patient's death was 6 days. The majority of palliative care consults (32%) came less than 7 days prior to the MAiD request and in another 25% of cases occurred the day of or after MAiD was requested. 35% of patients had no level of intervention form, or it was documented as 1 or 2 (prolongation of life remains a priority) at the time of the MAiD request and 19% were receiving life-prolonging interventions.

INTERPRETATION

We highlight ethical considerations relating to the timing of MAiD requests within the broader context of end-of-life care. Whether or not MAiD is conceptualised as morally distinct from other end-of-life options is likely to influence clinicians' approach to requests for MAiD as well as the ethical importance of our findings. We suggest that in the wake of the 2015 legislation, requests for MAiD have not always appeared to come after an exploration of other options as professional practice guidelines recommend.

Drugs Used for Euthanasia: A Repeated Population-Based Mortality Follow-Back Study in Flanders, Belgium, 1998-2013

CONTEXT

According to guideline recommendations, barbiturates and neuromuscular relaxants are the recommended drugs for euthanasia.

OBJECTIVES

To describe changes over time in drugs used to perform euthanasia and differences in case characteristics according to the drugs used.

METHODS

Repeated population-based mortality follow-back study among physicians attending a large representative sample of deaths in 1998, 2007, and 2013 in Flanders, Belgium.

RESULTS

In 1998, we identified 25 euthanasia cases (1.2% of all deaths), 142 cases in 2007 (2.0% of all deaths), and 349 cases in 2013 (4.6% of all deaths). Use of recommended drugs to perform euthanasia increased from 11.9% of euthanasia cases in 1998 to 55.3% in 2007 and 66.8% in 2013 (P < 0.001). In 2013, cases with recommended drugs compared with nonrecommended drugs more often involved requests expressed both orally and in writing (86.8%/14.1%; P < 0.001), consultation with colleague physicians (93.8%/69.1%; P < 0.001), and administration in the presence of another physician (98.3%/54.3%; P < 0.001), and were more often self-labeled by physicians as euthanasia (95.5%/0.9%; P < 0.001) and reported to the euthanasia review committee (92.3%/3.8%; P < 0.001). Between 2007 and 2013, physicians consistently labeled cases in which nonrecommended drugs were used as palliative sedation (72.8%/78.4%; P = 0.791) or alleviation of pain and symptoms (13.2%/15.0%; P > 0.999).

CONCLUSION

Physicians in Flanders are increasingly using the recommended drugs for euthanasia. This suggests that guidelines and training regarding the conduct and pharmacological aspects of euthanasia may have had important effects on the practice of euthanasia. However, the declining but persisting use of nonrecommended drugs requires further attention.

Research roundup

Synopses of a selection of recently published research articles of relevance to palliative care.