Euthanasia and assisted suicide: issues for social work practice

Characterizing Canadian Social Workers Willing to Be Involved in Medical Assistance in Dying for Persons Lacking Decisional Capacity

Medical assistance in dying (MAID) is available in Canada for competent persons meeting the legal requirements. Extending access to persons lacking decisional capacity is being considered. Social workers may be called upon to accompany these persons through the MAID process. As part of a larger survey, we asked social workers from Quebec whether they would be willing to be involved should advance requests for MAID be legalized. Of the 367 respondents, 291 replied that they would. Using multivariable logistic regression, we identified characteristics that distinguish them from the other social workers surveyed: importance of religious or spiritual beliefs, being born in Canada, having received assisted-death requests from families, professional experiences with MAID, and dreading the prospect of participating in MAID for persons lacking decisional capacity. These findings underline the need for educational interventions that would increase social workers' confidence in providing high-quality care to clients who opt for MAID.

Juror Decision Making and Euthanasia: Exploring the Role of Jury Nullification, Manner of Death, and Defendant-Decedent Relationship

In cases of euthanasia, determinations of guilt may be influenced by legal and extra-legal factors. This study explores the role that nullification instructions play in juror decision making. A defendant may be viewed as less culpable if the act was done out of mercy and jury nullification may occur as a result. We anticipated that these determinations may be influenced by the manner of death and the relational distance between the defendant and the decedent. It is unknown how euthanasia is viewed when it is performed by a physician compared to a family member or friend. To answer these questions, participants acted as mock jurors in a euthanasia case. The descriptions of the case varied by the presence of nullification instructions, the manner of death, and the defendant's relationship to the decedent. The results revealed significant effects of method of euthanasia and the type of defendant on juror verdicts. Jurors were most likely to acquit in a case that provided nullification instructions and involved a spouse using lethal injection for euthanasia. This finding suggests that different circumstances of a euthanasia case will affect jurors' propensity to focus on personal sympathies and interpretations. Limitations and future directions are discussed.

Social workers' experiences with medical assistance in dying: Survey findings from Quebec, Canada

As part of a larger survey, we asked social workers whether they had been involved in medical assistance in dying (MAID) so far. Of the 367 survey participants, 141 reported that they had. These were invited to describe their roles, needs, and sense of competence, focusing on their last MAID experience. Roles were diversified, beginning before and extending beyond the provision of MAID. Nearly 60% needed training on MAID. Perceived competence was lower among those lacking training. Findings point to educational needs that must be addressed to ensure the quality of end-of-life care and the well-being of social workers who engage in MAID.

ETHICS OF PROFESSIONAL ACTIVITIES OF SOCIAL WORKERS IN THE FIELD OF HEALTH: THE AMERICAN EXPERIENCE

OBJECTIVE

The aim: Coverage of the American experience of successful application of professional ethics of social workers in the field of health to solve complex ethical dilemmas in the activity of a social worker.

PATIENTS AND METHODS

Materials and methods: The methodological basis of the study was the use of an axiological approach in identifying the values and ethics of the professional activity of social workers, a competence approach in determining the competence of a social work specialist in the field of health in matters of professional ethics, an interdisciplinary approach in integrating the ethical competence of a social work specialist in the practice of solving ethical dilemmas in the field of health, including in the process of work of an interdisciplinary team of specialists.

CONCLUSION

Conclusions: The content and specifics of the practical application of the Code of Professional Ethics of the National Association of Social Workers of the USA in social work in the field of health were studied. It was determined that many situations in the practice of social work do not have simple answers when solving complex ethical issues in the field of health. Social workers, in addition to the values, principles and standards of the Code, in making decisions about professional actions in the field of health, must take into account their own beliefs and those of the client. The mechanism for the adjustment of difficult ethical choice cases in the practice of a social worker in the field of health is described.

Breaking bad news to cancer patients and their families: Attitudes toward death among Turkish physicians and their communication styles

To investigate how Turkish oncologists' attitudes toward death influence their emotional states, outlooks, and communication styles when breaking bad news to cancer patients and/or their families.

Cross-sectional study using self-completed questionnaires.

The study sample consisted of 35 physicians working at an oncology department. Physicians completed a quantitative one-time survey developed by the authors and the Death Attitude Profile-Revised (DAP-R).

Thirty-one physicians completed the survey and the DAP-R. A mean of 13.39 ± 8.82 minutes was allocated for breaking bad news; 87.1% of the participants avoided using the word "cancer" and 42% avoided using the word "death". The attitudes characterized by "death avoidance" and "fear of death" were found to be related to the emotional difficulty experienced by the physicians, and were also associated with less eye contact with the patient, and less attention paid to the language used while breaking bad news.

It is important for physicians to be aware of how their attitudes toward death affect their communication with patients during bad news. They should be provided in-service professional education, and therapeutic support.

Social Work Practice with Medical Assistance in Dying: A Case Study

Medical assistance in dying (MAiD) recently became legal in Canada, and social workers have an integral role providing psychosocial care to those considering this end-of-life care option. Research has found that most requests for assisted dying have a psychosocial dimension. Social workers are uniquely equipped to understand the personal and contextual factors informing the choice for MAiD and offer supports. A case example highlights practice opportunities for social workers throughout the MAiD process.

Euthanasia and other end of life in patients suffering from dementia

Medicine aims to relieve patient suffering and cure illness. To relieve suffering is the heart of what doctors do. However, respect for individual autonomy and self-determination are fundamental principles in Western medical ethics and decision-making, often expressed as a desire for control over the timing and manner of death. Patients who become demented often formulate advance euthanasia and assisted suicide directives. Dealing with such request is quite complex because of the specific medical and conflicting ethical questions they raise. Some specific medical and ethical issues arise regarding these substantive requirements when evaluating the euthanasia request of a person suffering from dementia. In jurisdictions that allow euthanasia, the most fundamental prerequisite for a person to make autonomous decisions is capacity. Whether anyone with moderate or severe dementia, and even some with mild dementia, could be deemed to be competent by these criteria is debatable, but during the course of their disease people with dementia sooner or later lose their capacity to make self-determined decisions.

Dying in the age of choice

Due to the unprecedented increase in the United States aging demographics, many more people are living longer and reaching older ages than ever before. However, a longer life is not necessarily a better life, as the vast majority will face a period of prolonged deteriorating health prior to death. Although notable efforts have been underway that are designed to improve the end-of-life experience, increasing numbers of individuals express a desire and/or act upon an intent to end their lives precipitously. Though still limited, the options to actively participate in their own deaths are growing. Requests for a hastened death can occur among people of all ages and includes those with advanced illness as well as others wanting to die due to unbearable suffering. This article provides an overview of the ongoing discourse about the experience of dying faced by many older adults, including aspects frequently associated with "a good death." The limitations of established practices which seek to provide a "better" dying experience are identified followed by discussion of the growing availability of alternative options. Reflective considerations are presented to guide practice vis-à-vis the changing landscape surrounding options in dying.

Attitudes toward euthanasia: implications for social work practice

This article reports the findings of a randomized general household survey that examined the attitudes of 618 Chinese respondents toward different types of euthanasia. The general public is found to agree with active euthanasia and non-voluntary euthanasia, but is neutral about passive euthanasia. Support for euthanasia is predicted by decreasing importance of religious belief, higher family income, experiences in taking care of terminally ill family members, being non-Protestants, and increasing age. Patients were perceived as the chief decision makers in euthanasian decisions. Finally, suggestions on social work practice and professional training are made.

Health care professionals' death attitudes, experiences, and advance directive communication behavior

The study surveyed 135 health care professionals (74 nurses, 32 physicians, and 29 social workers) to examine their personal death attitudes and experiences in relation to their reported advance directive communication practice behavior. Negative correlations were found between collaborating with other health care professionals regarding the directives and fear of death, avoidance of death, and escape acceptance of death. Approach acceptance of death positively correlated with initiating the discussion of advance directives. Practitioners indicating recent personal experiences with terminal illness reported disclosing more information about the documents.

Social work competencies in palliative and end-of-life care

Social workers from clinical, academic, and research settings met in 2002 for a national Social Work Leadership Summit on Palliative and End-of-Life Care. Participants placed the highest priority on the development and broad dissemination of a summary document of the state-of-the-art practice of social work in palliative and end-of-life care. Nine Summit participants reviewed the literature and constructed this detailed description of the knowledge, skills, and values that are requisite for the unique, essential, and appropriate role of social work. This comprehensive statement delineates individual, family, group, team, community, and organizational interventions that extend across settings, cultures, and populations and encompasses advocacy, education, training, clinical practice, community organization, administration, supervision, policy, and research. This document is intended to guide preparation and credentialing of professional social workers, to assist interdisciplinary colleagues in their collaboration with social workers, and to provide the background for the testing of quality indicators and "best practice" social work interventions.

Social work and end-of-life care: reviewing the past and moving forward

This paper reviews the professional literature with respect to the social work profession's involvement in end-of-life care. The search process was conducted by entering key words in various combinations to electronic databases. Eligible articles were required to address one of the following: roles and activities of social workers in providing end-of-life care; core principles valued by social workers in the provision of end-of-life care; and barriers to provision of effective end-of-life care. The literature from 1990 through July 2004 was searched most rigorously. Based on this review, suggestions for where the profession of social work should focus its energies are offered. These key areas include focusing on generating empirically-based knowledge for practice and policy analysis and developing a system of social work education that addresses the unique knowledge and skills needed to participate in end-of-life practice as competent and informed professional practitioners. Current initiatives with regard to critical areas are summarized.

Social workers' personal death attitudes, experiences, and advance directive communication behavior

This research surveyed 29 social workers to examine their personal death attitudes and experiences in relation to their advance directives communication practice behavior. The study measured death attitudes on 5 dimensions: fear, avoidance, neutral, approach, or escape acceptance of death. Participants' personal experiences with terminal illness and death were also assessed. Advance directive communication practices were operationalized as 7 phases: initiation of the topic, disclosure of information, identification of a surrogate decision-maker, discussion of treatment options, elicitation of patient values, interaction with family members, and collaboration with other health care professionals. Findings suggest that social workers' advance directive communication behavior differs by practitioners' death attitudes and experiences. Implications for social work education and professional development are discussed.

Amicus Curiae brief for the United States Supreme Court on mental health, terminal illness, and assisted death

The Supreme Court will hear the case of Gonzales v. Oregon in the fall of 2005 to determine if prescriptions written under Oregon's Death with Dignity law violate the Controlled Substances Act. The Attorney General of the United States also believes that hastening death is a public health danger because of the vulnerability of people with terminal illness, primarily because of the possibility of depression.

"We just happen to live here": two social workers share their stories about Oregon's Death with Dignity Law

This article is written more like a conversation with the reader rather than a strictly academic piece. The purpose is to share from a more personal perspective the unique circumstances and challenges faced by two social workers in Oregon as they grappled with the Death with Dignity Law. The law has been in effect for six years and a May 2004 decision from the Ninth U.S. Circuit Court allowed the law to remain a legal end-of-life option. Each writer has a unique voice on the process of social work involvement in practice, research, and policy since the law was originally passed in 1994.

Consideration of hastening death among hospice patients and their families

The purpose of this study was to describe hospice social workers' perceptions of cases where hospice patients or their family members expressed a desire to hasten the patient's death. Surveys were mailed to hospice social workers (n=212) in two Southeastern states. Response rate was 36%. Of the 73 respondents, 56.2% had a patient and 26.1% had a patient's family member express a desire to hasten the patient's death. Most patients had a cancer diagnosis (70.4%) and were predominantly male (66.6%), white (94.4%), and were married/had a partner (66.7%). Poor quality of life (28.3%) and concern for suffering (28.3%) were the most common reasons reported for the request to hasten death. These data suggest that the desire for hastened death is not uncommon among hospice patients. Social workers perceive these requests to be related primarily to unmet needs.

Washington State social workers' attitudes toward voluntary euthanasia and assisted suicide

This study examines attitudes and experiences concerning voluntary euthanasia (VE) and assisted suicide (AS) among 862 professional social workers from Washington State, USA. Although AS has been portrayed as more acceptable than VE, social workers make only a minor distinction in their support for the legalization of such acts (VE 72.4%; AS 77.6%). Only 26.6% agreed with the US Supreme Court's ruling that assisted suicide is not a constitutional right. More than 75% believe that social workers should be involved in the decision-making process with clients who are considering VE/AS. About 20% of social workers report being consulted about VE/AS issues either by clients or in their personal lives. Social workers employed in medical settings are more than twice as likely to be consulted about VE/AS than those employed in non-medical settings. Religious commitment explains some opposition to VE/AS for Protestants and Catholics, but not for other faiths. A small number of social workers (19) admitted to assisting the death of a patient by VE and 5 admitted to AS.

The role of values and experience in determining social workers' attitudes toward euthanasia and assisted suicide

This article reports results of a study examining the impact of personal and professional values and experience on 122 hospital social workers' attitudes toward euthanasia and assisted suicide. Respect for self-determination was rated as the most important consideration in end-of-life issues. Predictors of social workers' agreement that euthanasia should be legal were: self-determination, religious beliefs, educational level (BSW/MSW), and for assisted suicide were: religious beliefs, belief in the potential for abuse, educational level and participation in ethics training. The findings underscore the need for social workers' awareness of how an interplay of personal and professional factors in potentially explosive ethical issues may influence practice in health care settings.

Hospital social workers' attitudes toward euthanasia and assisted suicide

Euthanasia and assisted suicide are the subjects of increasing controversy in the health care setting. In this study of 122 hospital social workers' attitudes toward euthanasia and assisted suicide, many respondents reported agreement that both practices may be ethical, should be legal in some situations, and that they would be willing to participate in the practices. Almost one-fourth of the respondents have been asked by patients and families during their careers to discuss euthanasia and assisted suicide. The social workers also identified situations in which euthanasia and assisted suicide may be appropriate and safeguards that should apply if practices are legalized. Preparation for requests to discuss these practices, through awareness of their own beliefs and attitudes and becoming knowledgeable about current controversies, policies, and practices, is essential. By doing so, social workers will be ready to seize the opportunity to emerge as leaders of multidisciplinary discussion of complex ethical issues in health care.