Characteristics and outcomes of peer consultations for assisted dying request assessments: Cross-sectional survey study among attending physicians

Background

In most jurisdictions where assisted dying practices are legal, attending physicians must consult another practitioner to assess the patient's eligibility. Consequently, in some jurisdictions, they can rely on the expertise of trained assisted dying consultants (trained consultants). However, these peer consultations remain under-researched. We examined the characteristics and outcomes of peer consultations to assess an assisted dying request with trained consultants, and explored how these characteristics influence the performance of assisted dying.

Methods

We conducted a cross-sectional survey in 2019–2020 in Belgium among attending physicians who had consulted a trained consultant for an assisted dying request assessment (N = 904).

Results

The valid response rate was 56% (502/903). The vast majority of attending physicians (92%) who had consulted a trained consultant were general practitioners. In more than half of the consultations (57%), the patient was diagnosed with cancer. In 66%, the patient was aged 70 or older. Reported as the patients' most important reasons to request assisted dying: suffering without prospect of improving in 49% of the consultations, loss of dignity in 11%, pain in 9%, and tiredness of life in 9%. In the vast majority of consultations (85%), the attending physician consulted the trained consultant because of the expertise, and in nearly half of the consultations (46%) because of the independence. In more than nine out of ten consultations (91%), the consultant gave a positive advice: i.e., substantive requirements for assisted dying were met. Eight out of ten consultations were followed by assisted dying. The likelihood of assisted dying was higher in consultations in which loss of dignity, loss of independence in daily living, or general weakness or tiredness were reasons for the request.

Conclusion

Our findings indicate that the peer consultation practice with trained consultants is most often embedded in a primary care setting. Moreover, our study corroborates previous research in that assisted dying is performed relatively less frequently in patients with cancer and more often in patients with general deterioration. Our findings suggest that attending physicians hold peer consultations with trained consultants to endorse their own decision-making and to request additional support.

Assisted dying request assessments by trained consultants: changes in practice and quality - Repeated cross-sectional surveys (2008-2019)

OBJECTIVES

To study changes in the peer consultation practice of assessing assisted dying requests and its quality among trained 'Life End Information Forum' (LEIF) consultants in Belgium between 2008 and 2019.

METHODS

Cross-sectional surveys conducted in 2008 (N=132) and 2019 (N=527) among all registered LEIF consultants.

RESULTS

The response rate was 75% in 2008 and 57% in 2019. In 2019 compared with 2008, more LEIF consultants were significantly less than 40 years old (25%/10%, p=0.006) and at least 60 years old (34%/20%, p=0.006). In their activities regarding assessments of assisted dying requests over 12 months, we found a significant increase in the number of patients who did not meet the substantive requirements for assisted dying in 2019 compared with 2008 (1-4 patients: 41.1 %/58.8%, p=0.020). In their most recent assessments of an assisted dying request, LEIF consultants in 2019 made significantly more assessments of patients aged 80 years or older than in 2008 (31%/9%, p<0.001), and significantly fewer assessments for patients with cancer (53%/70%, p=0.034). Regarding adherence to quality criteria for consultation, LEIF consultants discussed unbearable suffering (87%/65%, p=0.003) and alternative treatments (palliative: 48 %/13%, p<0.001; curative: 28%/5%, p=0.002) significantly more often with the attending physician.

CONCLUSIONS

Changes in peer consultation practice and its quality among LEIF consultants likely reflect changes in assisted dying practice in general, as well as changes in LEIF consultations on more complex cases for which LEIF consultants' expertise is required.

The impact of the euthanasia assessment procedure: a qualitative interview study among adults with psychiatric conditions

BACKGROUND

Assisted dying for adults with psychiatric conditions (APC) is highly controversial but legally possible in a few countries, including Belgium. Previous research has suggested that the complex euthanasia assessment procedure may cause additional suffering in APC but may also induce positive experiences. This study reports on the impact of the euthanasia assessment procedure as experienced by APC on three counts: 1) their mental state, including death ideation; 2) their treatment trajectory; 3) their social relationships.

METHODS

We performed an in-depth qualitative interview study with 16 APC in Flanders, Belgium, who had voiced a euthanasia request between 2016-2020. Thematic coding was used.

FINDINGS

We interviewed 16 APC. Euthanasia assessment procedures brought out a plethora of experiences in APC, both favourable and unfavourable. Whereas thoughts of suicide remain present to a certain extent, being in the assessment procedure allows some APC to reconsider alternatives towards life, and also to attempt new treatment options. However, many APC experience ambivalence about the supposedly inherent desirability and dignity in euthanasia. Worries also surfaced about the rationale behind and effects of involvement of APCs' social circle, and about the impact it could have on them.

CONCLUSION

Further research, including other stakeholder perspectives, is recommended with a view to maximising favourable and minimising unfavourable impacts for all involved. In clinical practice attention to these impacts is paramount, and clear communication and management of expectations between physician and patient, seems appropriate to address the many ambivalent experiences that accompany APC during the euthanasia assessment procedure. Policy attention could in this regard go to clarifying certain sources of ambivalence and issues that are insufficiently addressed, such as modalities of relatives' involvement.

Concrete Experiences and Support Needs Regarding the Euthanasia Practice in Adults With Psychiatric Conditions: A Qualitative Interview Study Among Healthcare Professionals and Volunteers in Belgium

OBJECTIVE

Although euthanasia in the context of adult psychiatry is legalized in Belgium, it poses major ethical and clinical challenges for the health care professionals and volunteers involved. This study aimed to address these members' concrete experiences and support needs.

METHODS

A qualitative semi-structured interview study was conducted with 16 physicians and 14 other health care professionals and volunteers, with at least one concrete experience with euthanasia requests and procedures concerning adults with psychiatric conditions.

FINDINGS

Concrete experiences concerned the following 8 domains: (1) the impact of euthanasia on the clinical trajectory and (2) on the therapeutic relationship, (3) internal and (4) external collaborative partnerships, (5) patients' social inner circle (non-)involvement, (6) the use of recently published guidelines and, (7) the first criminal trials on this topic, and (8) the act of euthanasia. The following 8 main support needs emerged; (1) protocols addressing specific sub-populations and pathologies, (2) protocols specifically drawn up for non-medics, (3) guidance on how to adequately implement the two-track approach, (4) (after)care for patients, (5) (after)care for the health care team, (6) guidance on the patient's social inner circle involvement, (7) enhanced education measures, and (8) enhanced financial measures, including incentives for holistic, palliative care approaches.

CONCLUSION

The health care professionals and volunteers reported many positive and negative experiences in dealing with euthanasia requests in adult psychiatry. They reported several support needs across the extensive euthanasia trajectory, pertaining to concrete management of thorny issues that guidelines do not (yet) touch on. Important implications of our study relate to tackling these existing issues, and to paying sufficient attention to the impact of a euthanasia trajectory on all actors, including the patients and their social inner circle, involved.

Why adults with psychiatric conditions request euthanasia: A qualitative interview study of life experiences, motives and preventive factors

OBJECTIVE

As the empirical picture of adults with psychiatric conditions (further referred to as 'patients') requesting euthanasia is still incomplete, this study aims to deepen our understanding of why these patients request euthanasia, how this relates to the option of suicide, and what could have prevented these patients from considering death and requesting euthanasia.

METHODS

A qualitative study using in-depth, face-to-face interviews was conducted with 16 patients who had their euthanasia request under assessment in the period 2016-2020. Thematic coding was used.

FINDINGS

Most patients were in a state of feeling emotionally worn-out as a result of the many accumulated misfortunes and setbacks, leading to the all-pervasive sense that life is no longer worth living. Whereas some patients reported lifelong adversity, others struggled predominantly in later life. Whereas some patients longed for death strongly, others expressed ambivalence towards death ideation, and some even requested euthanasia to hear of their ineligibility for it, to restore hope and to (re)find meaning in life. patients valued euthanasia over suicide as being more dignified and acceptable, both for themselves and for their inner circle. With regard to preventive factors, patients posited the need for improved accessibility and quality of mental healthcare, as well as a profound change in society's perception of, and support for, these patients.

CONCLUSIONS

This study revealed the many complexities of euthanasia in the context of psychiatry, due to the many differences in patients' background characteristics, in their motives for requesting euthanasia, and the multi-layered aspects of mental suffering that go beyond the field of psychiatry.

Control Measures for Continuous Deep Sedation Until Death: A Framing Analysis of the Views of Physicians

Physicians have been subject to increasing external control to improve their medical practice, and scholars have theorized extensively about their opposition to such control. However, little empirical attention has been paid to the views and reasoning that lie behind this opposition. An in-depth understanding is necessary for enhancing the effectiveness and efficiency of external controls, and continuous deep sedation until death (CDS) is an interesting case in this regard. This study aims to explore how physicians frame control measures for CDS. We conducted 47 semi-structured interviews with Belgian physicians in 2019. A qualitative framing analysis was performed to analyze their views and reasoning. This study reveals that physicians approach CDS practice and control measures with different emphases. Controlling by mechanisms of professional self-regulation and state governance are put forward as appropriate means to improve CDS practice. Policymakers should take into consideration physicians' frames to develop sound control measures.

Validation of a skin and coat scoring protocol in dogs

Skin and coat scores have been used to assess changes in skin and coat quality in dogs. The aim of this study was to evaluate a skin and coat protocol in dogs of different coat types. Skin and coat of long-haired, short-haired and wire-haired dogs were scored for alopecia, glossiness, greasiness, softness, scaliness and overall skin and coat quality by ten observers. Intraobserver and interobserver agreement was assessed using kappa values. Thirty-six client-owned dogs were included in the study. The overall intraobserver agreement was moderate when assessing greasiness and glossiness and substantial when assessing alopecia, softness, scaliness and overall skin and coat quality. The overall interobserver agreement was only slight to fair for all features assessed. In conclusion, the proposed skin and coat scoring protocol assesses different aspects of the skin and coat quality in dogs and is easy and non-invasive. Scoring skin and coat quality over time is only reliable if performed by the same person.

Euthanasia in adults with psychiatric conditions: A descriptive study of the experiences of Belgian psychiatrists

To investigate the experience of psychiatrists who completed assessment procedures of euthanasia requests from adults with psychiatric conditions (APC) over the last 12 months. Between November 2018 and April 2019 a cross-sectional survey was sent to a sample of 753 psychiatrists affiliated with Belgian organisations of psychiatrists to gather detailed information on their latest experience with a completed euthanasia assessment procedure, irrespective of its outcome (i.e. euthanasia being performed or not). Information on 46 unique cases revealed that most APC suffered from comorbid psychiatric and/or somatic disorders, and had received different kinds of treatment for many years prior to their euthanasia request. Existential suffering was the main reason for the request. The entire procedure spanned an average of 14 months, and an average of 13.5 months in the 23 cases that culminated in the performance of euthanasia. In all cases, the entire procedure entailed multidisciplinary consultations, including with family and friends. Psychiatrists reported fewer difficulties in assessing due care criteria related to the APC's self-contemplation - for example, unbearable suffering on top of the due care criteria related to their medical condition; incurability due to lack of reasonable treatment perspectives. In a few cases in which euthanasia was the outcome, not all legal criteria were fulfilled in the reporting physicians' opinions. Both positive and negative experiences of the assessment procedure were reported: for example, reduced suicide risk for the APC; an emotional burden and a feeling of being pressured for the psychiatrist. This study confirms that euthanasia assessment in APC entails a lengthy process with diverse complexities, and psychiatrists require support in more than one respect if the assessments are to be handled adequately. Thorough evaluation of current guidelines is recommended: that is, to what extent the guidelines sufficiently address the complexities around (e.g.) assessing legal criteria or involving relatives. We formulate various avenues for further research to build on this study's insights and to fill remaining knowledge gaps.

Update van de behandeling van urineweginfecties bij honden en katten

Doorgaans worden bacteriële urineweginfecties bij kleine huisdieren beduidend langer behandeld met antibiotica dan bij mensen en het vermoeden bestaat dat urineweginfecties bij honden en katten volgens de oorspronkelijke internationale richtlijnen uit 2011 te lang worden behandeld. Naast kosten voor de eigenaar en mogelijke bijwerkingen voor het dier brengt dit het risico op de ontwikkeling van antibioticumresisentie bij dier en mens met zich mee. In 2019 zijn er nieuwe richtlijnen van de “International Society for Companion Animal Infectious Diseases” verschenen over de diagnose en behandeling van bacteriële urineweginfecties bij honden en katten. Het doel van dit artikel is om een overzicht te geven van de aangewezen behandeling (i. e. keuze van het antibioticum en duur van de therapie) bij de verschillende types bacteriële urine-weginfectie bij kleine huisdieren. Ook worden praktische tips meegegeven voor het definitief vaststellen van een urineweginfectie. Zo wordt in de eerste plaats zekerheid verkregen over de aanwezigheid van een bacteriële infectie als oorzaak van de aanwezige klachten en kan vervolgens ook een weloverwogen keuze worden gemaakt qua antibioticum, gebaseerd op het type urineweginfectie en het antibiogram. Ook de rol van niet-steroïdale ontstekingsremmers in de behandeling van lagere-urinewegklachten, in afwachting van het resultaat van een urinecultuur, wordt besproken. Tot slot is het belangrijk te beseffen dat niet elke positieve urinecultuur noodzakelijkerwijs een antibioticumtherapie inhoudt.

The engagement of psychiatrists in the assessment of euthanasia requests from psychiatric patients in Belgium: a survey study

BACKGROUND

Since its legalisation in 2002, the number of times euthanasia has been carried out in response to requests from adults with psychiatric conditions (APC) has continued to increase. However, little is known about why and how psychiatrists become engaged in the assessment of such euthanasia requests.

METHODS

A cross-sectional survey study was conducted between November 2018 and April 2019 of 499 psychiatrists affiliated with the Flemish Psychiatry Association. Chi square/Fisher's exact tests were performed to examine if, and to what extent, psychiatrists' backgrounds relate to their concrete experiences. The answers to the open question regarding motives for (non-) engagement were thematically coded.

RESULTS

Two hundred one psychiatrists participated, a response rate of 40%. During their careers, 80% of those responding have been confronted with at least one euthanasia request from an APC patient and 73% have become involved in the assessment procedure. Their engagement was limited to the roles of: referring physician (in 44% of the psychiatrists), attending physician (30%), legally required 'advising physician' (22%), and physician participating in the actual administration of the lethal drugs (5%). Within the most recent 12 months of practice, 61% of the respondents have been actively engaged in a euthanasia assessment procedure and 9% have refused at least once to be actively engaged due to their own conscientious objections and/or the complexity of the assessment. The main motive for psychiatrists to engage in euthanasia is the patient's fundamental right in Belgian law to ask for euthanasia and the psychiatrist's duty to respect that. The perception that they were sufficiently competent to engage in a euthanasia procedure was greater in psychiatrists who have already had concrete experience in the procedure.

CONCLUSIONS

Although the majority of psychiatrists have been confronted with euthanasia requests from their APC patients, their engagement is often limited to referring the request to a colleague physician for further assessment. More research is needed to identify the determinants of a psychiatrist's engagement in euthanasia for their APC patients and to discover the consequences of their non-, or their restricted or full engagement, on both the psychotherapeutic relationship and the course of the euthanasia request.

Belgian psychiatrists' attitudes towards, and readiness to engage in, euthanasia assessment procedures with adults with psychiatric conditions: a survey

BACKGROUND

Although the Belgian assessment pathway for legal euthanasia requires the engagement of at least one psychiatrist, little is known about psychiatrists' attitudes towards euthanasia for adults with psychiatric conditions (APC). This study aims to gauge psychiatrists' attitudes towards and readiness to engage in euthanasia assessment and/or performance procedures in APC.

METHODS

This cross-sectional survey study was performed between November 2018 and April 2019. The survey was sent to a sample of 499 eligible psychiatrists affiliated to the Flemish Association for Psychiatry, a professional association that aims to unite and represent all psychiatrists working in Flanders, the Dutch-speaking, northern part of Belgium. The Association's members comprise an estimated 80-90% of all psychiatrists active in Flanders. Only psychiatrists working with APC (83% of the association's total membership) were included. Factorial Anova and Chi Square tests were performed to examine if and to what extent psychiatrists' backgrounds were associated with, respectively, their attitudes and their readiness to play a role in euthanasia procedures concerning APC.

RESULTS

One hundred eighty-four psychiatrists completed the questionnaire (response rate 40.2%); 74.5% agree that euthanasia should remain permissible for APC. However, 68.9% question some of the approaches taken by other physicians during the euthanasia assessment and only half consider euthanasia assessment procedures compatible with the psychiatric care relationship. Where active engagement is concerned, an informal referral (68%) or preliminary advisory role (43.8%) is preferred to a formal role as a legally required advising physician (30.3%), let alone as performing physician (< 10%).

CONCLUSION

Although three quarters agree with maintaining the legal option of euthanasia for APC, their readiness to take a formal role in euthanasia procedures appears to be limited. More insight is required into the barriers preventing engagement and what psychiatrists need, be it education or clarification of the legal requirements, to ensure that patients can have their euthanasia requests assessed adequately.

Transfusies van bloedproducten bij de hond: een retrospectieve studie

De doelstelling van deze studie bestond uit het uitvoeren van een retrospectieve analyse van de transfusies die in het jaar 2018 aan honden werden toegediend in de Kliniek Kleine Huisdieren van de Faculteit Diergeneeskunde in Merelbeke, Universiteit Gent. In totaal werden 87 honden in deze studie ingesloten, die samen een totaal van 140 transfusies hebben gehad. Het aantal transfusies met “packed red blood cells” (n = 85) lag driemaal hoger dan het aantal toedieningen van “fresh frozen plasma” (n = 28) of vers volbloed (n = 27). De meest frequent gestelde diagnose was primaire immuungemedieerde hemolytische anemie en daarnaast lag bij opvallend veel honden, in vergelijking met eerdere studies, coumarine-intoxicatie aan de basis van het uitvoeren van een transfusie met bloedproducten. Transfusiereacties traden op bij 23,2% van de transfusies, waarbij koorts het vaakst werd gezien.

Development of a non-functional pancreatic neuroendocrine tumor and a duodenal ulceration after cholecystoduodenostomy in a cat

A six-year-old Ragdoll with previous extrahepatic biliary tract obstruction due to cholangiohepatitis, treated with cholecystoduodenostomy, was presented for acute vomiting, hyporexia, and weight loss. Abdominal ultrasound examination revealed randomly distributed hepatic nodules and dilated biliary ducts. Gastroduodenoscopy showed a patent cholecystoduodenostoma but disclosed a perforated duodenal ulceration. Conversion to celiotomy revealed extensive liver pathology, a discrete pancreatic nodule, and a duodenal ulcer opposite to the cholecystoduodenostoma. The cat was euthanized intra-operatively and necropsy was performed. The intrahepatic biliary tract of the right liver lobes was obstructed and severely dilated, whereas bile from the left lobes drained through the cholecystoduodenostoma. Histopathologic diagnoses were a primary pancreatic tumor, positive for glucagon on immunohistochemistry, with liver metastases, chronic purulent cholecystitis, and duodenal ulceration. To the authors’ knowledge, this is the first report in which the development of pancreatic neoplasia is described in a cat with a history of biliary tract disease.

Palliative Care Training: A Survey of Physicians in Australia and Europe

The purpose of this paper is to present data about the level and background characteristics of physicians’ training in palliative care in Australia (AU), Belgium (BE), Denmark (DK), Italy (IT), the Netherlands (NL), Sweden (SE) and Switzerland (CH) (n=16,486). The response rate to an anonymous questionnaire differed between countries (39%-68%). In most countries approximately half of all responding physicians had any formal training in palliative care (median: 3–10 days). Exceptions were NL (78%) and IT (35%). The most common type of training was a postgraduate course. Physicians in nursing home medicine (only in NL), geriatrics, oncology (not in NL), and general practice had the most training. In all seven countries, physicians with such training discussed options for palliative care and options to forgo life-sustaining treatment more often with their patients than did physicians without. Irrespective of earlier palliative care training, 87%-98% of the physicians wanted extended training.

The use of desoxycorticosterone pivalate in dogs with hypoadrenocorticism: a retrospective study of eight cases

In this article, the use of desoxycorticosterone pivalate is retrospectively reviewed in eight dogs with primary hypoadrenocorticism, presented at the Small Animal Department of Ghent University. The results showed that desoxycorticosterone pivalate provided adequate mineralocorticoid replacement in all cases, also in the dogs that had previously been treated with fludrocortisone acetate. A starting dosage of 1.5 – 2.2 mg/kg SC was used, with a fixed dosing interval of 28 days in most of the cases. Each time, prednisolone was added to the therapy as glucocorticoid supplementation. No side effects related to desoxycorticosterone pivalate therapy were noted and all owners were satisfied with the treatment consisting of desoxycorticosterone pivalate and prednisolone.

Attitudes, Sociodemographic Characteristics, and Actual End-of-Life Decisions of Physicians in Flanders, Belgium

Aim. To study the effect of sociodemographic and attitudinal determinants of physicians making end-of-life decisions (ELDs). Methods. The physicians having signed 489 consecutive death certificates in the city of Hasselt (Belgium) were sent an anonymous questionnaire regarding their ELDs and another on their attitudes toward voluntary euthanasia (EUTH) and physician-assisted suicide (PAS).Results.55% response rate. Nontreatment decisions occurred in 16.7% of all death cases; in 16%, there was potentially life-shortening use of drugs to alleviate pain and symptoms; in 4.8% of cases,death was deliberately induced by lethal drugs, including EUTH, PAS, and life termination without explicit request by the patient. In their attitudes toward EUTH and PAS, the 92 responding physicians clustered into 3 groups: positive and rule oriented, positive rule-adverse, and opposed. Cluster groupmembership, commitment to life stance, years of professional experience, and gender were each associated with specific ELD-making patterns.

Using continuous sedation until death for cancer patients: a qualitative interview study of physicians' and nurses' practice in three European countries

BACKGROUND

Extensive debate surrounds the practice of continuous sedation until death to control refractory symptoms in terminal cancer care. We examined reported practice of United Kingdom, Belgian and Dutch physicians and nurses.

METHODS

Qualitative case studies using interviews.

SETTING

Hospitals, the domestic home and hospices or palliative care units.

PARTICIPANTS

In all, 57 Physicians and 73 nurses involved in the care of 84 cancer patients.

RESULTS

UK respondents reported a continuum of practice from the provision of low doses of sedatives to control terminal restlessness to rarely encountered deep sedation. In contrast, Belgian respondents predominantly described the use of deep sedation, emphasizing the importance of responding to the patient's request. Dutch respondents emphasized making an official medical decision informed by the patient's wish and establishing that a refractory symptom was present. Respondents employed rationales that showed different stances towards four key issues: the preservation of consciousness, concerns about the potential hastening of death, whether they perceived continuous sedation until death as an 'alternative' to euthanasia and whether they sought to follow guidelines or frameworks for practice.

CONCLUSION

This qualitative analysis suggests that there is systematic variation in end-of-life care sedation practice and its conceptualization in the United Kingdom, Belgium and the Netherlands.

The language of sedation in end-of-life care: The ethical reasoning of care providers in three countries

The application of ethically controversial medical procedures may differ from one place to another. Drawing on a keyword and text-mining analysis of 156 interviews with doctors and nurses involved in end-of-life care (‘care providers’), differences between countries in care providers’ ethical rationales for the use of sedation are reported. In the United Kingdom, an emphasis on titrating doses proportionately against symptoms is more likely, maintaining consciousness where possible. The potential harms of sedation are perceived to be the potential hastening of social as well as biological death. In Belgium and the Netherlands, although there is concern to distinguish the practice from euthanasia, rapid inducement of deep unconsciousness is more acceptable to care providers. This is often perceived to be a proportionate response to unbearable suffering in a context where there is also greater pressure to hasten dying from relatives and others. This means that sedation is more likely to be organised like euthanasia, as the end ‘moment’ is reached, and family farewells are organised before the patient is made unconscious for ever. Medical and nursing practices are partly responses to factors outside the place of care, such as legislation and public sentiment. Dutch guidelines for sedation largely tally with the practices prevalent in the Netherlands and Belgium, in contrast with those produced by the more international European Association for Palliative Care whose authors describe an ethical framework closer to that reportedly used by UK care providers.

Factors that facilitate or constrain the use of continuous sedation at the end of life by physicians and nurses in Belgium: results from a focus group study

Continuous sedation at the end of life (CS) is the practice whereby a physician uses sedatives to reduce or take away a patient's consciousness until death. Although the incidence of CS is rising, as of yet little research has been conducted on how the administration of CS is experienced by medical practitioners. Existing research shows that many differences exist between medical practitioners regarding how and how often they perform CS. We conducted a focus group study to find out which factors may facilitate or constrain the use of continuous sedation by physicians and nurses. The participants often had clear ideas on what could affect the likelihood that sedation would be used. The physicians and nurses in the focus groups testified that the use of continuous sedation was facilitated in cases where a patient has a very limited life expectancy, suffers intensely, makes an explicit request and has family members who can cope with the stress that accompanies sedation. However, this 'paradigm case' was considered to occur only rarely. Furthermore, deviations from the paradigm case were said to be sometimes due to physicians initiating the discussion on CS too late or not initiating it at all for fear of inducing the patient. Deviations from the paradigm case may also occur when sedation proves to be too difficult for family members who are said to sometimes pressure the medical practitioners to increase dosages and speed up the sedation.

Bridging the Gap Between Continuous Sedation Until Death and Physician-Assisted Death

The distinction between continuous sedation until death (CSD) and physician-assisted death (PAD) has become a topic of medical ethical debate. We conducted 6 focus groups to examine how nursing home clinicians perceive this distinction. For some, the difference is clear whereas others consider CSD a form of euthanasia. Another group situates CSD between pain relief and ending life. Arguments for these perspectives refer to the following themes: intention, dosage of sedative drugs, unconsciousness, and the pace of the dying process. Generally, CSD is considered emotionally easier to deal with since it entails a gradual dying process. Nursing home clinicians have diverging perceptions of the relation between CSD and PAD; some consider CSD to be more than a purely palliative measure, that is, also as a means to hasten death.

Continuous sedation until death: the everyday moral reasoning of physicians, nurses and family caregivers in the UK, The Netherlands and Belgium

BACKGROUND

Continuous sedation is increasingly used as a way to relieve symptoms at the end of life. Current research indicates that some physicians, nurses, and relatives involved in this practice experience emotional and/or moral distress. This study aims to provide insight into what may influence how professional and/or family carers cope with such distress.

METHODS

This study is an international qualitative interview study involving interviews with physicians, nurses, and relatives of deceased patients in the UK, The Netherlands and Belgium (the UNBIASED study) about a case of continuous sedation at the end of life they were recently involved in. All interviews were transcribed verbatim and analysed by staying close to the data using open coding. Next, codes were combined into larger themes and categories of codes resulting in a four point scheme that captured all of the data. Finally, our findings were compared with others and explored in relation to theories in ethics and sociology.

RESULTS

The participants' responses can be captured as different dimensions of 'closeness', i.e. the degree to which one feels connected or 'close' to a certain decision or event. We distinguished four types of 'closeness', namely emotional, physical, decisional, and causal. Using these four dimensions of 'closeness' it became possible to describe how physicians, nurses, and relatives experience their involvement in cases of continuous sedation until death. More specifically, it shined a light on the everyday moral reasoning employed by care providers and relatives in the context of continuous sedation, and how this affected the emotional impact of being involved in sedation, as well as the perception of their own moral responsibility.

CONCLUSION

Findings from this study demonstrate that various factors are reported to influence the degree of closeness to continuous sedation (and thus the extent to which carers feel morally responsible), and that some of these factors help care providers and relatives to distinguish continuous sedation from euthanasia.

Continuous sedation until death: moral justifications of physicians and nurses--a content analysis of opinion pieces

Continuous sedation until death (CSD), the act of reducing or removing the consciousness of an incurably ill patient until death, often provokes medical-ethical discussions in the opinion sections of medical and nursing journals. A content analysis of opinion pieces in medical and nursing literature was conducted to examine how clinicians define and describe CSD, and how they justify this practice morally. Most publications were written by physicians and published in palliative or general medicine journals. Terminal Sedation and Palliative Sedation are the most frequently used terms to describe CSD. Seventeen definitions with varying content were identified. CSD was found to be morally justified in 73% of the publications using justifications such as Last Resort, Doctrine of Double Effect, Sanctity of Life, Autonomy, and Proportionality. The debate over CSD in the opinion sections of medical and nursing journals lacks uniform terms and definitions, and is profoundly marked by 'charged language', aiming at realizing agreement in attitude towards CSD. Not all of the moral justifications found are equally straightforward. To enable a more effective debate, the terms, definitions and justifications for CSD need to be further clarified.

Canine lymphoma: a retrospective study (2009 – 2010)

This study reviews the medical records of 56 dogs diagnosed with lymphoma based on the cytological and/or histological results between January 1, 2009 and December 31, 2010. Most of the dogs were middle-aged to old, and were diagnosed with multicentric lymphoma (ML) (n=36). The majority of the dogs were presented in stages III to V (n=55) and substage b (n=43). A complete blood count and serum biochemistry, urinalysis, serum protein electrophoresis, thoracic radiographs and/or abdominal ultrasound were performed. The results correlated with previously described results in the literature. Therapy was initiated in 80% of the dogs (n=45). After diagnosis, the median survival time of 62% of these dogs (n=28) treated with only prednisolone was 32 days (range 3 – 224 days). For 24% of the dogs (n=11) treated with chemotherapy, the median survival time was 119 days (range 11 - 273 days). Surgical resection of the macroscopic tumor was performed in the remaining six dogs (13%). Three of these dogs received subsequent prednisolone therapy. The median survival time of these six dogs was 47 days (range 0 – 669 days). The dogs that received chemotherapy had significantly longer survival times than those treated with only prednisolone, although negative prognostic factors were present in all of the cases treated with chemotherapy.

Continuous deep sedation at the end of life and the 'natural death' hypothesis

Surveys in different countries (e.g. the UK, Belgium and The Netherlands) show a marked recent increase in the incidence of continuous deep sedation at the end of life (CDS). Several hypotheses can be formulated to explain the increasing performance of this practice. In this paper we focus on what we call the 'natural death' hypothesis, i.e. the hypothesis that acceptance of CDS has spread rapidly because death after CDS can be perceived as a 'natural' death by medical practitioners, patients' relatives and patients. We attempt to show that the label 'natural' cannot be unproblematically applied to the nature of this end-of-life practice. We argue that the labeling of death following CDS as 'natural' death is related to a complex set of mechanisms which facilitate the use of this practice. However, our criticism does not preclude the view that CDS may be clinically and ethically justified in many cases.

Expressed wishes and incidence of euthanasia in advanced lung cancer patients

This study explores expressed wishes and requests for euthanasia (i.e. administration of lethal drugs at the explicit request of the patient), and incidence of end-of-life decisions with possible life-shortening effects (ELDs) in advanced lung cancer patients in Flanders, Belgium. We performed a prospective, longitudinal, observational study of a consecutive sample of advanced lung cancer patients and selected those who died within 18 months of diagnosis. Immediately after death, the pulmonologist/oncologist and general practitioner (GP) of the patient filled in a questionnaire. Information was available for 105 out of 115 deaths. According to the specialist or GP, one in five patients had expressed a wish for euthanasia; and three in four of these had made an explicit and repeated request. One in two of these received euthanasia. Of the patients who had expressed a wish for euthanasia but had not made an explicit and repeated request, none received euthanasia. Patients with a palliative treatment goal at inclusion were more likely to receive euthanasia. Death was preceded by an ELD in 62.9% of patients. To conclude, advanced lung cancer patients who expressed a euthanasia wish were often determined. Euthanasia was performed significantly more among patients whose treatment goal after diagnosis was exclusively palliative.

Preferred and actual involvement of advanced lung cancer patients and their families in end-of-life decision making: a multicenter study in 13 hospitals in Flanders, Belgium

CONTEXT

Death is often preceded by medical decisions that potentially shorten life (end-of-life decisions [ELDs]), for example, the decision to withhold or withdraw treatment. Respect for patient autonomy requires physicians to involve their patients in this decision making.

OBJECTIVES

The objective of this study was to examine the involvement of advanced lung cancer patients and their families in ELD making and compare their actual involvement with their previously stated preferences for involvement.

METHODS

Patients with Stage IIIb/IV non-small cell lung cancer were recruited by physicians in 13 hospitals and regularly interviewed between diagnosis and death. When the patient died, the specialist and general practitioner were asked to fill in a questionnaire.

RESULTS

Eighty-five patients who died within 18 months of diagnosis were studied. An ELD was made in 52 cases (61%). According to the treating physician, half of the competent patients were not involved in the ELD making, one-quarter shared the decision with the physician, and one-quarter made the decision themselves. In the incompetent patients, family was involved in half of cases. Half of the competent patients were involved less than they had previously preferred, and 7% were more involved. Almost all of the incompetent patients had previously stated that they wanted their family involved in case of incompetence, but half did not achieve this.

CONCLUSION

In half of the cases, advanced lung cancer patients-or their families in cases of incompetence-were not involved in ELD making, despite the wishes of most of them. Physicians should openly discuss ELDs and involvement preferences with their advanced lung cancer patients.

Attitudes and practices of physicians regarding physician-assisted dying in minors

OBJECTIVE

To investigate attitudes towards physician-assisted death in minors among all physicians involved in the treatment of children dying in Flanders, Belgium over an 18-month period, and how these are related to actual medical end-of-life practices.

DESIGN

Anonymous population-based postmortem physician survey.

SETTING

Flanders, Belgium.

PARTICIPANTS

Physicians signing death certificates of all patients aged 1-17 years who died between June 2007 and November 2008.

MAIN OUTCOME MEASURES

Attitudes towards physician-assisted death in minors and actual end-of-life practices in the deaths concerned.

RESULTS

124 physicians for 70.5% of eligible cases (N=149) responded. 69% favour an extension of the Belgian law on euthanasia to include minors, 26.6% think this should be done by establishing clear age limits and 61% think parental consent is required before taking life-shortening decisions. Cluster analysis yielded a cluster (67.7% of physicians) accepting of, and a cluster (32.2% of physicians) reluctant towards physician-assisted death in minors. Controlling for physician specialty and patient characteristics, acceptant physicians were more likely to engage in practices with the intention of shortening a patient's life than were reluctant physicians.

CONCLUSION

A majority of surveyed Flemish physicians appear to accept physician-assisted dying in children under certain circumstances and favour an amendment to the euthanasia law to include minors. The approach favoured is one of assessing decision-making capacity rather than setting arbitrary age limits. These stances, and their connection with actual end-of-life practices, may encourage policy-makers to develop guidelines for medical end-of-life practices in minors that address specific challenges arising in this patient group.

Is continuous sedation at the end of life an ethically preferable alternative to physician-assisted suicide?

The relatively new practice of continuous sedation at the end of life (CS) is increasingly being debated in the clinical and ethical literature. This practice received much attention when a U.S. Supreme Court ruling noted that the availability of CS made legalization of physician-assisted suicide (PAS) unnecessary, as CS could alleviate even the most severe suffering. This view has been widely adopted. In this article, we perform an in-depth analysis of four versions of this "argument of preferable alternative." Our goal is to determine the extent to which CS can be considered to be an alternative to PAS and to identify the grounds, if any, on which CS may be ethically preferable to PAS.

Continuous deep sedation until death in Belgium: a survey among nurses

CONTEXT

Continuous deep sedation (CDS) is a subject of important debate, but until now nurses have rarely been questioned about their involvement and perceptions.

OBJECTIVES

To study the communication process between nurses and patients, relatives, or physicians before starting CDS, and how nurses perceive this end-of-life practice.

METHODS

In 2007, we surveyed 1678 nurses in Flanders, Belgium, who, in an earlier survey, had reported caring for one or more patients who received an end-of-life decision within the previous year. Nurses were surveyed about their most recent case.

RESULTS

The response rate was 75.8%: 250 nurses reported a case of CDS (64.4% hospital, 18.4% home, and 17.2% nursing home). In, respectively, 25.8% and 75.4%, the patient and relatives had communicated with the nurse about the CDS. In 17.6%, there was no communication between the nurse and the physician about the CDS; in 29.1%, the physician and nurse only exchanged information; and in 23.4%, they made the decision jointly. Making the decision jointly was associated with a more positive evaluation of the cooperation with the physician (adjusted odds ratio 10.9 and 95% confidence interval 3.0, 39.2). Nurses perceived CDS as partly intended to hasten death partially in 48.4% and explicitly in 28.4% of cases, estimating possible or certain life shortening in 95.6%.

CONCLUSION

Nurses in different health care settings are often involved in communication about CDS. They see it mainly as a practice intended to hasten death, with a life-shortening effect; guidelines should recommend clear discussions between caregivers in which the physician states the purpose and estimated effect of the decision.

Preferences of patients with advanced lung cancer regarding the involvement of family and others in medical decision-making

OBJECTIVE

To explore the preferences of competent patients with advanced lung cancer regarding involvement of family and/or others in their medical decision-making, and their future preferences in case of loss of competence.

METHODS

Over 1 year, physicians in 13 hospitals in Flanders, Belgium, recruited patients with initial non-small–cell lung cancer, stage IIIb or IV. The patients were interviewed with a structured questionnaire every 2 months until the fourth interview and every 4 months until the sixth interview.

RESULTS

At inclusion, 128 patients were interviewed at least once; 13 were interviewed 6 consecutive times. Sixty-nine percent of patients wanted family members to be involved in medical decision-making and this percentage did not change significantly over time. One third of these patients did not achieve this preference. Ninety-four percent of patients wanted family involvement if they lost competence, 23% of these preferring primary physician control over decision-making, 41% shared physician and family control, and 36% primary family control. This degree of preferred family involvement expressed when competent did not change significantly over time at population level, but did at individual level; almost half the patients changed their minds either way at some point during the observation period.

CONCLUSIONS

The majority of patients with lung cancer wanted family involvement in decision-making, and almost all did so in case of future loss of competence. However, as half of the patients changed their minds over time about the degree of family involvement they wanted if they lost competence, physicians should regularly rediscuss a patient's preferences.

Continuous deep sedation at the end of life of children in Flanders, Belgium

CONTEXT

Few guidelines have yet been put forth for continuous deep sedation in pediatrics, and empirical data on the use of this practice in minors are rare.

OBJECTIVES

To estimate the incidence of continuous deep sedation in minor patients (aged 1-17) and describe the characteristics of, and the decision-making process before, continuous deep sedation.

METHODS

An anonymous population-based postmortem survey was mailed to all physicians signing the death certificates of all patients aged 1-17 years who died between June 2007 and November 2008 in Flanders, Belgium. The questionnaire concerned whether or not continuous deep sedation was used at the end of life and measured characteristics of sedation and the decision-making process preceding it.

RESULTS

Response rate was 70.5% (n=165). Of all children, 21.8% had been continuously and deeply sedated at the end of life. Duration of sedation was one week or less in 72.4% of cases, and artificial nutrition and hydration were administered until death in 54.3% of cases. Benzodiazepines were used as the sole drug for sedation in 19.4% of cases, benzodiazepines combined with morphine in 50%, and morphine as the sole drug in 25%. In 23.5% of cases, physicians had the explicit intention, or the concurrent intention, to hasten death. Only 3.0% of patients requested sedation and 6.1% consented. Parents consented in 77.8% of cases and requested sedation in 16.7%.

CONCLUSION

Minor patients were commonly kept in continuous deep sedation or coma until death in Flanders, Belgium. Given the high incidence of the practice and indications that it is often used without involving the patient--and sometimes with a life-shortening intention--the development of specific guidelines for sedation in children might contribute to due care practice.

Are patients' preferences for information and participation in medical decision-making being met? Interview study with lung cancer patients

We examined the degree to which newly diagnosed patients with advanced lung cancer wanted to be informed and involved in medical decision-making, and whether the patients felt their preferences were met. Patients from 13 hospitals in Flanders were interviewed with a standard questionnaire. A total of 128 patients (68%) participated. Of the patients who wanted to be informed about life expectancy, half (53%) reported they were informed, and of those who wanted to be informed about palliative care and end-of-life decisions, 25% and 31% said they were informed, respectively. With regard to participation in medical decision-making (in general, about treatment, transfer or end-of-life), patients who preferred the doctor to make decisions or those who preferred to make the decision themselves often achieved this (in their perception), while patients who wanted an in-between position with some involvement, often did not. To conclude, preferences of patients with lung cancer for information concerning delicate topics and for shared decision-making with the physician were not well met.

Trends in medical end-of-life decision making in Flanders, Belgium 1998-2001-2007

In 2002, Belgium saw the enactment of 3 laws concerning euthanasia, palliative care, and patient rights that are likely to affect end-of-life decision making. This report examines trends in the occurrence and decision-making process of end-of-life practices in different patient groups since these legal changes. A large-scale retrospective survey in Flanders, Belgium, previously conducted in 1998 and 2001, was repeated in 2007. Questionnaires regarding end-of-life practices and the preceding decision-making process were mailed to physicians who certified a representative sample (N = 6927) of death certificates. The 2007 response rate was 58.4%. In patient groups in which the prevalence of life-ending drug use without explicit patient request has dropped, performance of euthanasia and assisted suicide has increased. The consistent increase in intensified pain and symptom alleviation was found in all patient groups except cancer patients. In 2007, competent patients were slightly more often involved in the discussion of end-of-life practices than in previous years. Over the years, involvement of the patient in decision making was consistently more likely among younger patients, cancer patients, and those dying at home. Physicians consulted their colleagues more often than in previous years for euthanasia and nontreatment decisions. The euthanasia law and emerging palliative care culture have substantially affected the occurrence and decision making for end-of-life practices in Belgium. Efforts are still needed to encourage shared end-of-life decision making, as some patients would benefit from advance care planning.

End-of-life care policies in Flemish residential care facilities accommodating persons with intellectual disabilities

OBJECTIVE

This article aims to describe the presence, content and implementation strategies of written policies on end-of-life decisions in Flemish residential care facilities (RCFs) accommodating persons with intellectual disabilities (ID), and to describe training, education and quality assessments of end-of-life care.

METHODS

A cross-sectional mail survey was conducted among general directors of all RCFs accommodating persons with ID (n = 140) in Flanders, Belgium. Institutions were asked to provide us with a copy of their end-of-life care policy documents for content analysis.

RESULTS

Of the 140 institutions, 84 (60%) completed the questionnaire and 25 institutions provided 45 policy documents. Presence of policies on specific end-of-life decisions with a possible life-shortening effect lay between 18% (palliative sedation) and 26% (withdrawing or withholding of life-prolonging treatment). The content analysis showed that the focus in the majority of these policy documents is on palliative care, while end-of-life decisions with a possible life-shortening effect are mentioned but rarely elaborated on. Furthermore, few documents incorporate the distinctive features and needs of persons with ID regarding end-of-life care. On the other hand, half of the institutions trained and educated their professional care providers in some aspects of end-of-life care while one-third assessed the satisfaction of residents and families on several of these aspects. However, more than half reported explicitly that they have no plans for such assessments.

CONCLUSIONS

The presence of end-of-life care policies is low in Flemish RCFs and their content is not very specific for persons with ID.

Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases

OBJECTIVES

To estimate the rate of reporting of euthanasia cases to the Federal Control and Evaluation Committee and to compare the characteristics of reported and unreported cases of euthanasia. Design Cross sectional analysis. Setting Flanders, Belgium.

PARTICIPANTS

A stratified at random sample was drawn of people who died between 1 June 2007 and 30 November 2007. The certifying physician of each death was sent a questionnaire on end of life decision making in the death concerned.

MAIN OUTCOME MEASURES

The rate of euthanasia cases reported to the Federal Control and Evaluation Committee; physicians' reasons for not reporting cases of euthanasia; the relation between reporting and non-reporting and the characteristics of the physician and patient; the time by which life was shortened according to the physician; the labelling of the end of life decision by the physician involved; and differences in characteristics of due care between reported and unreported euthanasia cases.

RESULTS

The survey response rate was 58.4% (3623/6202 eligible cases). The estimated total number of cases of euthanasia in Flanders in 2007 was 1040 (95% CI 970 to 1109), thus the incidence of euthanasia was estimated as 1.9% of all deaths (95% CI 1.6% to 2.3%). Approximately half (549/1040 (52.8%, 95% CI 43.9% to 60.5%)) of all estimated cases of euthanasia were reported to the Federal Control and Evaluation Committee. Physicians who perceived their case as euthanasia reported it in 93.1% (67/72) of cases. Cases of euthanasia were reported less often when the time by which life was shortened was less than one week compared with when the perceived life shortening was greater (37.3% v 74.1%; P<0.001). Unreported cases were generally dealt with less carefully than reported cases: a written request for euthanasia was more often absent (87.7% v 17.6% verbal request only; P<0.001), other physicians and caregivers specialised in palliative care were consulted less often (54.6% v 97.5%; 33.0% v 63.9%; P<0.001 for both), the life ending act was more often performed with opioids or sedatives (92.1% v 4.4%; P<0.001), and the drugs were more often administered by a nurse (41.3% v 0.0%; P<0.001).

CONCLUSIONS

One out of two euthanasia cases is reported to the Federal Control and Evaluation Committee. Most non-reporting physicians do not perceive their act as euthanasia. Countries debating legalisation of euthanasia should simultaneously consider developing a policy facilitating the due care and reporting obligations of physicians.

Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey

BACKGROUND

Legalization of euthanasia and physician-assisted suicide has been heavily debated in many countries. To help inform this debate, we describe the practices of euthanasia and assisted suicide, and the use of life-ending drugs without an explicit request from the patient, in Flanders, Belgium, where euthanasia is legal.

METHODS

We mailed a questionnaire regarding the use of life-ending drugs with or without explicit patient request to physicians who certified a representative sample (n = 6927) of death certificates of patients who died in Flanders between June and November 2007.

RESULTS

The response rate was 58.4%. Overall, 208 deaths involving the use of life-ending drugs were reported: 142 (weighted prevalence 2.0%) were with an explicit patient request (euthanasia or assisted suicide) and 66 (weighted prevalence 1.8%) were without an explicit request. Euthanasia and assisted suicide mostly involved patients less than 80 years of age, those with cancer and those dying at home. Use of life-ending drugs without an explicit request mostly involved patients 80 years of older, those with a disease other than cancer and those in hospital. Of the deaths without an explicit request, the decision was not discussed with the patient in 77.9% of cases. Compared with assisted deaths with the patient's explicit request, those without an explicit request were more likely to have a shorter length of treatment of the terminal illness, to have cure as a goal of treatment in the last week, to have a shorter estimated time by which life was shortened and to involve the administration of opioids.

INTERPRETATION

Physician-assisted deaths with an explicit patient request (euthanasia and assisted suicide) and without an explicit request occurred in different patient groups and under different circumstances. Cases without an explicit request often involved patients whose diseases had unpredictable end-of-life trajectories. Although opioids were used in most of these cases, misconceptions seem to persist about their actual life-shortening effects.