Misconception between palliative care and euthanasia among Thai general practitioners: a cross-sectional study.

BACKGROUND: Palliative care lower medical expenses and enhances quality of life, but misconception with euthanasia delays timely care and makes inappropriate patient management. OBJECTIVE: To examine the magnitude of misconceptions between palliative care and euthanasia among Thai general practitioners, explore the association with knowledge, attitudes, and practical experience, and assess the association between misconception and confidence in practicing and referring patients to palliative care centers. METHODS: All 144 general practitioners who were going to start residency training at Maharaj Nakorn Chiang Mai Hospital in 2021 participated in this observational cross-sectional study. A chi-square test was utilized to examine the relationship between misconception and knowledge, attitude, practical experience, confidence to practice, and confidence to refer patients. Multivariable logistic regression was carried out while controlling for age, sex, knowledge, attitude, and experience to examine the relationship between misconception and confidence to practice and refer patients for palliative care. Statistical significance was defined at p < 0.05. RESULTS: About 41% of general physicians had misconceptions regarding palliative care and euthanasia. High knowledge was associated with a lower level of misconception (p = 0.01). The absence of misconceptions was weakly associated with a higher level of confidence in practicing palliative care, with an adjusted odds ratio of 1.51 (95% confidence interval 0.73 to 3.10, p = 0.07). CONCLUSION: High misconception rates between palliative care and euthanasia among young Thai physicians might impact their confidence in delivering palliative care. Training initiatives for medical students and practitioners can mitigate misconceptions, fostering better palliative care utilization in Thailand.

Continuous palliative sedation until death: a qualitative study of palliative care clinicians' experiences.

BACKGROUND: The practice of continuous palliative sedation until death is the subject of much medical and ethical debate, which is reflected in the inconsistency that persists in the literature regarding the definition and indications of palliative sedation. AIM: This study aims to gain a better understanding of palliative care clinicians' experiences with continuous palliative sedation. DESIGN: We conducted a qualitative study based on focus group discussions. SETTING/PARTICIPANTS: We conducted six focus groups with a total of 28 palliative care clinicians (i.e., 15 nurses, 12 physicians, and 1 end-of-life doula) from diverse care settings across Canada, where assisted dying has recently been legalized. RESULTS: An interpretative phenomenological analysis was used to consolidate the data into six key themes: responding to suffering; grappling with uncertainty; adapting care to ensure ongoing quality; grounding clinical practice in ethics; combining medical expertise, relational tact, and reflexivity; and offering an alternative to assisted death. CONCLUSIONS: Interaction with the patient's family, uncertainty about the patient's prognosis, the concurrent practice of assisted dying, and the treatment of existential suffering influence the quality of sedation and indicate a lack of clear palliative care guidelines. Nevertheless, clinicians exhibit a reflective and adaptive capacity that can facilitate good practice.

Expanding the Use of Continuous Sedation Until Death and Physician-Assisted Suicide.

The controversy over the equivalence of continuous sedation until death (CSD) and physician-assisted suicide/euthanasia (PAS/E) provides an opportunity to focus on a significant extended use of CSD. This extension, suggested by the equivalence of PAS/E and CSD, is designed to promote additional patient autonomy at the end-of-life. Samuel LiPuma, in his article, "Continuous Sedation Until Death as Physician-Assisted Suicide/Euthanasia: A Conceptual Analysis" claims equivalence between CSD and death; his paper is seminal in the equivalency debate. Critics contend that sedation follows proportionality protocols for which LiPuma's thesis does not adequately account. Furthermore, sedation may not eliminate consciousness, and as such LiPuma's contention that CSD is equivalent to neocortical death is suspect. We not only defend the equivalence thesis, but also expand it to include additional moral considerations. First, we explain the equivalence thesis. This is followed by a defense of the thesis against five criticisms. The third section critiques the current use of CSD. Finally, we offer two proposals that, if adopted, would broaden the use of PAS/E and CSD and thereby expand options at the end-of-life.

Euthanasia and assisted suicide in neurological diseases: a systematic review.

OBJECTIVE: To identify the neurological diseases for which euthanasia and assisted suicide are most frequently requested in the countries where these medical procedures are legal and the specific characteristics of euthanasia in some of these diseases, and to show the evolution of euthanasia figures. METHODS: We conducted a systematic literature review. RESULTS: Dementia, motor neuron disease, multiple sclerosis, and Parkinson's disease are the neurological diseases that most frequently motivate requests for euthanasia or assisted suicide. Requests related to dementia constitute the largest group, are growing, and raise additional ethical and legal issues due to these patients' diminished decision-making capacity. In some countries, the ratios of euthanasia requests to all cases of multiple sclerosis, motor neuron disease, or Huntington disease are higher than for any other disease. CONCLUSIONS: After cancer, neurological diseases are the most frequent reason for requesting euthanasia or assisted suicide.

Legalisation of euthanasia and assisted suicide: advanced cancer patient opinions - cross-sectional multicentre study.

OBJECTIVES: The French government voted a new law in February 2016 called the Claeys-Leonetti Law, which established the right to deep and continuous sedation, confirmed the ban on euthanasia and ruled out physician-assisted suicide. The aim of this work was to gather the opinion of patients on continuous sedation and the legalisation of medical assistance in dying and to explore determinants associated with favourable and unfavourable opinions. METHODS: This was a French national prospective multicentre study between 2016 and 2020. RESULTS: 331 patients with incurable cancer suffering from locally advanced or metastatic cancer in 14 palliative care units were interviewed. 48.6% of participants expressed a favourable opinion about physician-assisted suicide and 27.2% an unfavourable opinion about its legalisation. Regarding euthanasia, 52% of patients were in favour of its legalisation. In univariate analysis, the only factor determining opinion was belief in God. CONCLUSIONS: While most healthy French people are in favour of legalising euthanasia, only half of palliative care patients expressed this opinion. Medical palliative care specialists were largely opposed to euthanasia. The only determining factor identified was a cultural factor that was independent of the other studied variables. This common factor was found in other studies conducted on cohorts from other countries. This study contributes to the knowledge and thinking about the impact of patients' personal beliefs and values regarding their opinions about euthanasia and assisted suicide. TRIAL REGISTRATION NUMBER: NCT03664856.

[Selected legal aspects of end-of-life care : Euthanasia, palliative sedation and emergency medicine]. / Ausgewählte juristische Aspekte der Medizin am Lebensende : Sterbehilfe, palliative Sedierung und Notfälle.

The law distinguishes between several forms of intentional participation in life-shortening or life-ending acts ("euthanasia"). Therapy limitation is permitted or even required if the prerequisites for a medical intervention are no longer present. In contrast, active-direct killing (upon request) is categorically prohibited (§ 216 "Strafgesetzbuch" [StGB]). Considering the "fundamental right to self-determined dying", however, there is now a clear tendency to narrow the scope of punishable offences. This liberal "spirit of time" has already prevailed for assisted suicide, provided that it is carried out in a "freely responsible" manner. For pain therapy to reduce suffering, risks may be taken in light of the protection of life; however, here too, legitimization is required through the principle of actual or at least presumed consent. There are challenges in assessing and executing the patient's will in (suicidal) emergency situations, especially the adherence to autonomously made decisions on death.

Palliative sedation: autonomy, suffering, and euthanasia.

PURPOSE OF REVIEW: This contemporary and novel review of palliative sedation explores some of the distinctive ethical problems associated with that intervention. It is timely in light of recent reviews of palliative care guidelines on the topic and given the current public debates around the related but distinct practice of euthanasia. RECENT FINDINGS: The main themes discussed are patient autonomy, the nature of suffering and how to alleviate it, and the relationship between palliative sedation and euthanasia. SUMMARY: First, palliative sedation poses a significant problem for patient autonomy, both in terms of securing informed consent and in terms of the ongoing effect on individual well-being. Second, as an intervention to alleviate suffering, it is appropriate only in limited cases and counterproductive in others, for example, where an individual values their ongoing psychological or social agency more than the relief of pain or negative experience. Third, people's ethical views about palliative sedation are often coloured by their understanding of the legal and moral status of assisted dying and euthanasia; this is unhelpful and occludes the interesting and urgent ethical questions raised by palliative sedation as a distinct end-of-life intervention.

Institutional Objection to Voluntary Assisted Dying in Victoria, Australia: An Analysis of Publicly Available Policies.

BACKGROUND: Victoria was the first Australian state to legalize voluntary assisted dying (elsewhere known as physician-assisted suicide and euthanasia). Some institutions indicated they would not participate in voluntary assisted dying. The Victorian government issued policy approaches for institutions to consider OBJECTIVE: To describe and analyse publicly available policy documents articulating an institutional objection to voluntary assisted dying in Victoria. METHODS: Policies were identified using a range of strategies, and those disclosing and discussing the nature of an institutional objection were thematically analysed using the framework method. RESULTS: The study identified fifteen policies from nine policymakers and developed four themes: (1) extent of refusal to participate in VAD, (2) justification for refusal to provide VAD, (3) responding to requests for VAD, and (4) appeals to state-sanctioned regulatory mechanisms. While institutional objections were stated clearly, there was very little practical detail in most documents to enable patients to effectively navigate objections in practice. CONCLUSION: This study demonstrates that despite having clear governance pathways developed by centralized bodies (namely, the Victorian government and Catholic Health Australia), many institutions' public-facing policies do not reflect this guidance. Since VAD is contentious, laws governing institutional objection could provide greater clarity and regulatory force than policies alone to better balance the interests of patients and non-participating institutions.

Could palliative sedation be seen as unnamed euthanasia?: a survey among healthcare professionals in oncology.

BACKGROUND: In 2016 a French law created a new right for end-of-life patients: deep and continuous sedation maintained until death, with discontinuation of all treatments sustaining life such as artificial nutrition and hydration. It was totally unprecedented that nutrition and hydration were explicitly defined in France as sustaining life treatments, and remains a specificity of this law. End- of-life practices raise ethical and practical issues, especially in Europe actually. We aimed to know how oncology professionals deal with the law, their opinion and experience and their perception. METHODS: Online mono-centric survey with closed-ended and open-ended questions in a Cancer Comprehensive Centre was elaborated. It was built during workshops of the ethics committee of the Institute, whose president is an oncologist with a doctoral degree in medical ethics. 58 oncologists and 121 nurses-all professionals of oncological departments -, received it, three times, as mail, with an information letter. RESULTS: 63/ 179 professionals answered the questionnaire (35%). Conducting end-of-life discussions and advanced care planning were reported by 46/63 professionals. In the last three months, 18 doctors and 7 nurses faced a request for a deep and continuous sedation maintained until death, in response to physical or existential refractory suffering. Artificial nutrition and even more hydration were not uniformly considered as treatment. Evaluation of the prognosis, crucial to decide a deep and continuous sedation maintained until death, appears to be very difficult and various, between hours and few weeks. Half of respondents were concerned that this practice could lead to or hide euthanasia practices, whereas for the other half, this new law formalised practices necessary for the quality of palliative care at the end-of-life. CONCLUSION: Most respondents support the implementation of deep and continuous sedation maintained until death in routine end-of-life care. Nevertheless, difficulty to stop hydration, confusion with euthanasia practices, ethical debates it provokes and the risk of misunderstanding within teams and with families are significant. This is certainly shared by other teams. This could lead to a multi-centric survey and if confirmed might be reported to the legislator.

Cryonics, euthanasia, and the doctrine of double effect.

In 1989, Thomas Donaldson requested the California courts to allow physicians to hasten his death. Donaldson had been diagnosed with brain cancer, and he desired to die in order to cryonically preserve his brain, so as to stop its further deterioration. This case elicits an important question: is this a case of euthanasia? In this article, we examine the traditional criteria of death, and contrast it with the information-theoretic criterion. If this criterion is accepted, we posit that Donaldson's case would have been cryocide, but not euthanasia. We then examine if cryocide is an ethically feasible alternative to euthanasia. To do so, we rely on the ethical doctrine of double effect.

Documentation of Sedation in Palliative Care: A Scoping Review of Requirements, Recommendations, and Templates.

Objective: To identify and describe requirements, recommendations, and templates for the documentation of sedation in adult palliative care. Introduction: International literature shows inconsistency in clinical practice regarding sedation in palliative care accompanied by legal, ethical, and medical uncertainties. Documentation in general serves as proof for previous treatments. In the context of intentional sedation to relieve suffering at the end of life, documentation provides a clear demarcation against practices of euthanasia. Inclusion Criteria: Articles with full-text version published in English or German since 2000, covering documentation requirements, recommendations, monitoring parameters or templates for sedation in adult palliative care were included. Methods: Scoping review following the JBI methodology. Search in online databases, websites of professional associations in palliative care, reference lists of relevant publications, the archive of the German "Journal of Palliative Medicine" and databases for unpublished literature were used. Search terms included "palliative care,' "sedation," and "documentation." The search was conducted from January 2022 to April 2022 with an initial hand search in November 2021. Data were screened and charted by one reviewer after conducting a pilot test of the criteria. Results: From the initial 390 articles (database search), 22 articles were included. In addition, 15 articles were integrated from the hand search. The results can be clustered in two sets of items, regarding either the documentation before or during sedation. The documentation requirements referred both to inpatient and homecare settings but in many cases, a clear assignment was missing. Conclusions: The guidelines analyzed in this study rarely cover setting-specific differences in documentation and often treat documentation as minor topic. Further research is needed addressing legal and ethical concerns of health care teams and, therefore, help to improve treatment of patients suffering from otherwise intractable burden at the end of life.

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.

[State of the art in palliative sedation]. / État des lieux de la sédation en situations palliatives.

The right to deep and continuous sedation maintained until death was introduced by the law known as the Claeys-Leonetti law. It is no longer a question of reversible sedation, but of maintaining the patient in a deep sleep, without waking, until death. It can be put into care in specific cases. The  borderline between euthanasia and this sedation implemented at the end of life lies in the intentionality of the medical act.

Neonatal euthanasia in the context of palliative and EoL care.

Neonatal deaths can be categorized in 5 modes along the dimension of intervention and physiology. This classification can be helpful to analyze the choices that can be made in end-of-life care in the NICU. In the Netherlands, neonatal euthanasia became an optional 6th mode of death since publication and legalization of the Groningen Protocol. This paper summarizes the history, legal status and ethical justification of the Groningen Protocol, and describes end-of-life practice in the subsequent years. Since the implementation of the Groningen Protocol, the practice of neonatal euthanasia has almost disappeared. Simultaneously, there has been spectacular growth in neonatal palliative care programs in the Netherlands. Is there still a need for this last-resort option?

Long-term development of assisted suicide in Switzerland: analysis of a 20-year experience (1999-2018).

AIMS OF THE STUDY: The legalisation of assisted suicide is one of the most debated topics in the field of medical ethics worldwide. In countries in which assisted suicide is not legal, public discussions about its approval also encompass considerations of the long-term consequences that such legalisation would bring, for example, how many people will use this option, from what conditions would they be suffering, would there be differences between male and female assisted suicide and which developments and trends could be expected if there were to be a marked increase of cases of assisted suicide over time? METHODS: In order to answer these questions, we present the development of assisted suicide in Switzerland over a 20-year period (1999-2018; 8738 cases) using data from the Swiss Federal Statistical Office. RESULTS: During the observation period, the number of assisted suicides rose significantly: when four 5-year periods (1999-2003, 2004-2008, 2009-2013, 2014-2018) were analysed, the number of assisted suicide cases doubled over each period compared with the preceding one (Χ = 206.7, 270.4 and 897.4; p <0.001). The percentage of assisted suicides among all deaths rose from 0.2% (1999-2003; n = 582) to 1.5% (2014-2018: n = 4820). The majority of people who chose assisted suicide were elderly, with increasing age over time (median age in 1999-2003: 74.5 years vs 2014-2018: 80 years), and with a predominance of women (57.2% vs 42.8%). The most common underlying condition for assisted suicide was cancer (n = 3580, 41.0% of all assisted suicides). Over time, assisted suicide increased similarly for all underlying conditions; however, the proportion in each disease group remained unchanged. CONCLUSIONS: It is a matter of one's viewpoint whether the rise of assisted suicide cases should be considered alarming or not. These figures reflect an interesting social development but still do not appear to represent a mass phenomenon.

Assisted suicide a 20th century problem, Palliative care a 21st century solution.

Assisted suicide and euthanasia are two forms of what is being called 'assisted dying', and they are touted by proponents as "progressive" and "compassionate". In fact, they are, on the contrary, relics from the last century: today, in the 21st century, we have moved beyond such archaic solutions - we now have, instead, proper evidence-based palliative care. It is this that should be demanded for all. This article will dispel the myths around dying that are often cited. It will also explore the oft-overlooked tragedies generated by assisted suicide, in the hope you, the reader, can be better informed about this retrogressive practice.