Although palliative care and legalised euthanasia are both based on the medical and ethical values of patient autonomy and caregiver beneficence and non-maleficence,1 they are often viewed as antagonistic causes. A popular perception, for instance, is that palliative care is the province of religiously motivated people and the advocacy of euthanasia that of agnostics or atheists.2 3 The European Association for Palliative Care has voiced concerns that legalising euthanasia would be the start of a slippery slope resulting in harm to vulnerable patients such as elderly and disabled people and that it would impede the development of palliative care by appearing as an alternative.4 Data from the Netherlands and Belgium, where euthanasia is legal, do not provide any evidence of a slippery slope.5 6 Here, we focus on the effect of the process of legalisation of euthanasia on palliative care and vice versa by reviewing the published historical, regulatory, and epidemiological evidence
Rurik Löfmark, Tore Nilstun, Colleen Cartwright, Susanne Fische, Agnes van der Heide, Freddy Mortier, Michael Norup, Lorenzo Simonato and Bregje D Onwuteaka-Philipsen for the EURELD Consortium
The book strives for as complete and dispassionate a description of the situation as possible and covers in detail: the substantive law applicable to euthanasia, physician-assisted suicide, withholding and withdrawing treatment, use of pain relief in potentially lethal doses, terminal sedation, and termination of life without a request (in particular in the case of newborn babies); the process of legal development that has led to the current state of the law; the system of legal control and its operation in practice; and, the results of empirical research concerning actual medical practice.
Test Santé vient de publier les résultats d'une enquête sur les actes de fin de vie et l'euthanasie. Elle est le prolongement de l’enquête récente sur les soins palliatifs. Pour cela, Test Santé a donné la parole aux personnes concernées : proches, médecins et infirmiers. Il en ressort que les soins palliatifs, aussi efficaces soient-ils, n'empêchent pas certains de souhaiter mourir. L’enquête souligne le fait que la demande vient le plus souvent exclusivement du patient lui-même (47% des cas contre 38% de la famille), et c’est encore plus vrai pour les patients en soins palliatifs (61%). Par ailleurs, Test Achats constate que l’euthanasie joue un rôle dans le débat sur la qualité de la fin de vie et que celle-ci est meilleure lorsque l’euthanasie est appliquée «à un moment plus naturel de la mort » (ou même avant dans certains cas) plutôt qu’après un acharnement thérapeutique.
John Coggon The German National Ethics Council has recently published its Opinion on Self- Determination and Care at the End of Life. 1 The Opinion raises and attempts to resolve issues that are troubling many people in many jurisdictions. Perhaps unsurprisingly, given the well-rehearsed range of views on euthanasia, assisted-suicide, suicide, and care for the dying, the Council’s Opinion is neither extreme in its suppositions nor in its proposals. This may not satisfy campaigners and commentators who sit on the polar edges of the debate, but it represents a predictable compromise, and will satisfy medical practitioners and those who are increasingly concerned with the inadequacy of palliative care for the elderly, the dying, and the chronically sick.
The National Ethics Council has intensively discussed the issues involved in dealing responsibly with dying. It has perused a large volume of material, obtained expert opinions, consulted with doctors and other medical specialists, and held meetings in Augsburg and Münster at which it exposed itself to public debate. The outcome is enshrined in the Opinion now presented. Self-determination and care at the end of life continues the examination of the themes addressed in the Opinion The advance directive published in June 2005. The present analysis, in conjunction with the clarification of terminology here proposed, may facilitate interpretation of the recommendations set out in that Opinion.
There is evidence from outside the UK to show that physicians’ religious beliefs influence their decision making at the end of life. This UK study explores the belief system of consultants, nurse key workers & specialist registrars & their attitudes to decisions which commonly must be taken when caring for individuals who are dying. Results showed that consultants’ religion & belief systems differed from those of nurses & the population they served. Consultants & nurses had statistically significant differences in their attitudes to common end of life decisions with consultants more likely to continue hydration & not withdraw treatment. Nurses were more sympathetic to the idea of PAS for unbearable suffering. This study shows the variability in belief system and attitudes to end of life decision making both within and between clinical groups. The personal belief system of consultants was not shown to affect their overall attitudes to withdrawing life-sustaining treatment or PAS.
In the linked study (doi:10.1136/bmj.b2772), Van den Block and colleagues report a national mortality follow-back study of end of life care in Belgium conducted during 2005 and 2006. The findings are a valuable contribution to understanding the context of dying in Belgium. They detail the frequency of team based palliative care; involvement of generalists; use of intensive alleviation of symptoms, which can extend to palliative sedation (termed continuous deep sedation); and the incidence of euthanasia and physician assisted suicide. However, the authors’ interpretation of the data and the conclusions they reach raise questions. Their conclusion that life shortening decisions, including euthanasia and physician assisted suicide, are not related to a lower use of palliative care in Belgium and often occur within the context of multidisciplinary care, misrepresents the frequencies they report and is tangential to the main findings.
End of life decisions that shorten life, including euthanasia or physician assisted suicide, are not related to a lower use of palliative care in Belgium and often occur within the context of multidisciplinary care.
But there is evidence that some clinicians may already be using continuous deep sedation (CDS), as a form of "slow euthanasia". Research suggests use of CDS in Britain is particularly high - accounting for about one in six of all deaths.
Van den Block and colleagues’ paper about end of life decision making and end of life care provides important data to support the debate about physicians’ role in death and dying. Their finding that end-of-life decision making seems to be associated with a high use of palliative care is not surprising, because a protracted dying process with much suffering may be expected to result in both a high use of palliative care and a high frequency of end-of-life decisions, especially for assertive patients with clear preferences concerning the end stage of their lives. More importantly, the study’s results suggest that palliative care is not able to prevent physicians and patients from making medical decisions that hasten death. This may be due to insufficient quality, that should be further improved, but it may also be indicative of principal limitations of palliative care, that apparently cannot address all suffering at the end of life.
A national survey of 3733 UK doctors reporting on the care of 2923 people who had died under their care is reported here. Results show that there was no time to make an ‘end-of-life decision’ (deciding to provide, withdraw or withhold treatment) for 8.5% of those reporting deaths. A further 55.2% reported decisions which they estimated would not hasten death and 28.9% reported decisions they had expected to hasten death. A further 7.4% reported deaths where they had to some degree intended to hasten death. Where patients or someone else had made a request for a hastened death, doctors were more likely to report expecting or at least partly intending to hasten death. Doctors usually made these decisions in consultation with colleagues, relatives and, where feasible, with patients.
Subsequent to an intensive three-year period of reflection, the CMQ is revealing its perspective and conclusions today regarding end-of-life care and euthanasia. The CMQ embraces the point of view of the patient who is confronting imminent and inevitable death. In such a situation, the patient looks to their physician and generally requests that they be able to die without undue suffering and with dignity. Neither surveys, nor attorneys, nor politicians can properly advise the physician and the patient facing this situation. In the majority of cases, the patient and their doctor find the appropriate analgesia that respects the ethical obligation of physicians not to preserve life at any cost, but rather, when the death of a patient appears to be inevitable, to act so that it occurs with dignity and to ensure that the patient obtains the appropriate support and relief.
A TV presenter's on-air confession that he killed his ailing lover is to be investigated by Nottinghamshire Police. Ray Gosling, 70, told the BBC's Inside Out programme he had smothered the unnamed man who was dying of Aids. Pressure group Care Not Killing said it was "bizarre" the BBC had not told police of the admission when it was filmed in December. The BBC said it was under no obligation to report to police ahead of broadcast but would co-operate with the inquiry. During a documentary on death and dying the Nottingham filmmaker said he had made a pact with his lover to act if his suffering increased. In the BBC East Midlands programme, broadcast on Monday, he told how he smothered the man with a pillow while he was in hospital after doctors told him that there was nothing further that could be done for him.