Voluntary Stopping Eating and Drinking.

Voluntary stopping of eating and drinking (VSED) is a deliberate, self-initiated attempt to hasten death in the setting of suffering refractory to optimal palliative interventions or prolonged dying that a person finds intolerable. Individuals who consider VSED tend to be older, have a serious but not always imminently terminal illness, place a high value on independence, and have significant illness burden. VSED can theoretically be performed independent of clinician assistance and therefore avoids many of the ethical and legal concerns associated with physician-assisted dying or other palliative measures of last resort, However, VSED is an intense process fraught with new sources of somatic and emotional suffering for individuals and their caregivers, so VSED is best supervised by an experienced, well-informed clinician who can provide appropriate pre-intervention assessment, anticipatory guidance, medical treatment of symptoms, and emotional support. Before initiation of VSED, clinicians should carefully screen for inadequately treated psychiatric conditions, unaddressed symptoms, existential suffering, and evidence of coercion-consultation from palliative medicine, psychiatry, or ethics is often indicated. The most common symptoms encountered after starting VSED are extreme thirst, hunger, dysuria, progressive disability, delirium, and somnolence. Although physiologically similar to cessation of artificial nutrition and hydration, the onset and management of symptoms is often different. We propose an organized system for evaluating individual appropriateness for VSED, anticipatory guidance, and management of symptoms associated with VSED. A brief review of ethical and legal considerations follows.

End-of-life decisions in perinatal care: A view from health-care providers in Mexico.

OBJECTIVE: To examine the opinions of a perinatal health team regarding decisions related to late termination of pregnancy and severely ill newborns. MATERIALS AND METHODS: An anonymous questionnaire was administered to physicians, social workers, and nurses in perinatal care. Differences were evaluated using the chi square and Student's t tests. RESULTS: When considering severely ill fetuses and newborns, 82% and 93% of participants, respectively, opted for providing palliative care, whereas 18% considered feticide as an alternative. Those who opted for palliative care aimed to diminish suffering and those who opted for intensive care intended to protect life or sanctity of life. There was poor knowledge about the laws that regulate these decisions. CONCLUSIONS: Although there is no consensus on what decisions should be taken with severely ill fetuses or neonates, most participants considered palliative care as the first option, but feticide or induced neonatal death was not ruled out.

End-of-life decisions in perinatal care: A view from health-care providers in Mexico / Decisiones sobre el final de la vida en la atención perinatal: Una visión del equipo de salud en México

Objective. To examine the opinions of a perinatal health team regarding decisions related to late termination of pregnancy and severely ill newborns. Materials and Methods. An anonymous questionnaire was administered to physicians, social workers, and nurses in perinatal care. Differences were evaluated using the chi square and Student's t tests. Results. When considering severely ill fetuses and newborns, 82% and 93% of participants, respectively, opted for providing palliative care, whereas 18% considered feticide as an alternative. Those who opted for palliative care aimed to diminish suffering and those who opted for intensive care intended to protect life or sanctity of life. There was poor knowledge about the laws that regulate these decisions. Conclusions. Although there is no consensus on what decisions should be taken with severely ill fetuses or neonates, most participants considered palliative care as the first option, but feticide or induced neonatal death was not ruled out.

Objetivo. Explorar la opinión del equipo de salud sobre las decisiones relacionadas con la atención de fetos y neonatos gravemente enfermos. Material y métodos. Se aplicó un cuestionario anónimo a médicos, trabajadoras sociales y enfermeras perinatales. Las diferencias se evaluaron con las pruebas chi cuadrada y t de Student. Resultados. Al tratar fetos y neonatos gravemente enfermos, 82 y 93% de los participantes optaron, respectivamente, por atención paliativa. El 18% consideró el feticidio como alternativa. Quienes optaron por atención paliativa, lo hicieron para disminuir el sufrimiento, mientras que los que eligieron cuidados intensivos lo hicieron para proteger la vida o la sacralidad de la vida. Nuestro estudio mostró un pobre conocimiento de las leyes que regulan estas decisiones. Conclusiones. Aun cuando no existe un consenso sobre las decisiones que deben tomarse con fetos o neonatos gravemente enfermos, la mayoría consideró como primera opción los cuidados paliativos, aunque el feticidio y la muerte neonatal inducida no se descartaron.

Primary care patients hastening death by voluntarily stopping eating and drinking.

PURPOSE: Little is known about the role family physicians play when a patient deliberately hastens death by voluntarily stopping eating and drinking (VSED). The purpose of this study was to gain more insight for family physicians when confronted with patients who wish to hasten death by VSED. We aimed to describe physicians' involvement in VSED, to describe characteristics and motives of their patients, and to describe the process of VSED in terms of duration, as well as common symptoms in the last 3 days of life. METHODS: We undertook a survey of a random national sample of 1,100 family physicians (response rate 72%), and 500 of these physicians received questions about their last patient who hastened death by VSED. RESULTS: Of the 978 eligible physicians, 708 responded (72.4%); 46% had cared for a patient who hastened death by VSED. Of the 500 physicians who received the additional questions, 440 were eligible and 285 (64.8%) responded; they described 99 cases of VSED. Seventy percent of these patients were aged older than 80 years, 76% had severe disease (27% with cancer), and 77% were dependent on others for everyday care. Frequent reasons for the patients' death wish were somatic (79%), existential (77%), and dependence (58%). Median time until death was 7 days, and the most common symptoms before death were pain, fatigue, impaired cognitive functioning, and thirst or dry throat. Family physicians were involved in 62% of cases. CONCLUSIONS: Patients who hasten death by VSED are mostly in poor health. It is not unlikely for family physicians to be confronted with VSED. They can play an important role in caring for these patients and their proxies by informing them of VSED and by providing support and symptom management during VSED.

Withdrawal of artificial nutrition: influence of prior experience on the perception of caregivers.

CONTEXT: In spite of the existence of clinical guidelines and a legal framework in France, the withdrawal of artificial nutrition (AN) in palliative care remains a difficult situation for caregivers who are confronted with this reality. OBJECTIVES: To describe the perception of caregivers on the withdrawal of AN and to compare this perception between caregivers who have already been confronted with this situation and those who have not. METHODS: Cross-sectional survey questionnaire of nurses and nurses' aides (n = 274) working in medicine, surgery, and palliative care departments of a regional hospital. RESULTS: Of the caregivers, 59.5% declared having been confronted with the withdrawal of AN in their professional practice. This was associated with a better perception by these caregivers even if their knowledge on the criteria to be considered in the decision was not significantly modified. CONCLUSION: The coherence of the withdrawal of AN with the personal beliefs of the caregivers, already high in the absence of being confronted with this practice, is better among caregivers who have been confronted with this situation. The lack of information perceived by caregivers should prompt us to develop additional training on the withdrawal of AN, its objectives, and its clinical consequences.

[Attitudes towards euthanasia: The impact of experiencing end-of-life care]. / Einstellungen zur Sterbehilfe.Welchen Einfluss hat die Pflege eines sterbenskranken Angehörigen?

BACKGROUND: It is a matter of debate whether euthanasia should be part of medical practice. OBJECTIVES: The current study investigates the attitudes of bereaved family members of cancer patients towards euthanasia. MATERIALS AND METHODS: We conducted a survey with 211 people who had recently lost a close relative to cancer. Participants were asked whether euthanasia should be part of medical practice.Two logistic regression models were calculated in order to determine the factors influencing the attitude towards active euthanasia and assisted suicide. RESULTS: About 70% and 75% of the respondents approved active euthanasia and assisted suicide, respectively. Religious denomination and psychological distress had a significant impact on the attitude towards active euthanasia. About 10%of the deceased patients had asked for active euthanasia. CONCLUSIONS: There was no difference between bereaved family members and the general population regarding the acceptance of euthanasia. Attitudes towards active euthanasia are associated with psychological distress and shaped by cultural values rather than by the experience of end-of-life care.

Israeli Dying Patient Act: physician knowledge and attitudes.

OBJECTIVES: The recently enacted Israeli Dying Patient Act was designed to strike balance between enhancing patient autonomy in end-of-life decision making and cultural/religious norms that are in opposition to active euthanasia and physician-assisted suicide (PAS). The current study evaluated physician attitudes regarding active and passive euthanasia, and their knowledge of specific aspects of the law. METHODS: A survey was administered to a convenience sample of hospital-based physicians treating terminal patients. Physicians were queried about their attitudes regarding euthanasia and PAS. Physicians were also queried about specific aspects of the law and whether they had sufficient resources to uphold the law. RESULTS: Surveys were distributed to 270 physicians and 100 were returned and evaluated (37%). Nearly all physicians supported passive euthanasia (withholding treatment), whereas over 40% maintained that active forms of euthanasia should be allowed for terminal patients in severe physical pain. Multivariate analysis showed a negative relationship between support for more active forms of euthanasia and physicians' self-reported religiosity. Physicians cited lack of time as a reason for not complying with the new law. Physicians had a familiarity with the general aspects of the new legislation, but a large proportion was not aware of the specifics of the law. CONCLUSIONS: Compared with previous surveys, a larger number of physicians support passive euthanasia. A sizable percentage of physicians would be willing to participate in active euthanasia and even PAS. Attitudes toward euthanasia are influenced by religious factors.

Euthanasia and end-of-life practices in France and Germany. A comparative study.

The objective of this paper is to understand from a sociological perspective how the moral question of euthanasia, framed as the "right to die", emerges and is dealt with in society. It takes France and Germany as case studies, two countries in which euthanasia is prohibited and which have similar legislation on the issue. I presuppose that, and explore how, each society has its own specificities in terms of practical, social and political norms that affect the ways in which they deal with these issues. The paper thus seeks to understand how requests for the "right to die" emerge in each society, through both the debate (analysis of daily newspapers, medical and philosophical literature, legal texts) and the practices (ethnographic work in three French and two German hospitals) that elucidate the phenomenon. It does so, however, without attempting to solve the moral question of euthanasia. In spite of the differences observed between these two countries, the central issue at stake in their respective debates is the question of the individual's autonomy to choose the conditions in which he or she wishes to die; these conditions depend, amongst others, on the doctor-patient relationship, the organisation of end-of-life care in hospital settings, and more generally, on the way autonomy is defined and handled in the public debate.

[End of life in France]. / La fin de vie en France.

Two major changes in end-of-life management have occured in recent decades: first, because of the increase in life expectancy and the resulting aging of the population, most deaths now involve old or very old people; second, more than two-thirds of deaths occur in a hospital or an institution. Our fellow citizens are afraid of suffering and death. They wish for a peaceful death, as rapid as possible and, in recent surveys, say they favour euthanasia. Yet euthanasia is illegal in France and in most other Western countries (with the exception of the Benelux nations). Palliative care ensures dignity in death, without anxiety of suffering, and is expanding rapidly in France. Léonetti's law of 22 April 2005 ensures the protection of the weakest, who should never be considered unworthy of life, yet is poorly known to the public and even to physicians. It now needs to be applied in practice.

[End-of-life care and end-of-life medical decisions: the ITAELD study]. / Cure di fine vita e decisioni mediche: lo studio ITAELD.

OBJECTIVE: To describe the attitudes towards end of life care and the practice of end-of-life medical decisions with possible life-shortening effect among Italian physicians. DESIGN: Cross sectional study (last death among the assisted patients in the last 12 months was considered). SETTING AND PARTICIPANTS: In the year 2007, 5,710 GPs and 8,950 hospital physicians were invited all over Italy to participate in the ITAELDstudy through anonymous mail questionnaire. MAIN OUTCOME MEASURES: Proportion of agreement with statements on end-of-life care issues. Proportion of deaths with an end-of-life medical decision. RESULTS: The response rate was 19.2%. The 65% of respondents agreed with the duty to respect any non-treatment request of the competent patient, the 55% agreed with the same duty in case of advanced directives, the 39% in case of proxy's request. The 53% of respondents agreed with the ethical acceptability of active euthanasia in selected cases. Among 1,850 deaths the 57.7% did not receive any end-of-life medical decision. For a further 21.0% no decision was possible, being sudden and unexpected deaths. In the remaining 21.3% at least one end-of-life medical decision was reported: 0.8% was classified as physician assisted death, 20.5% as non-treatment decision. Among all deceased the 19.6% were reported to have been deeply sedated. Being favourable to the use of opioids in terminal patients was associated to non-treatment decisions with possible but non-intentional life shortening effect; agreeing with the duty to fully respect any actual non-treatment request of the competent patient was associated to end-of life medical decisions with intentional life-shortening effect (adjusted OR>10 in both cases). CONCLUSIONS: The life stance and ethical beliefs of physicians determine their behaviour at the end of life wherever specific statements of law are lacking. Therefore education and debate are needed on these issues.

Variation in attitudes towards artificial hydration at the end of life: a systematic literature review.

PURPOSE OF REVIEW: Artificial hydration in end-of-life care is an important and emotive topic that frequently raises concerns from patients, relatives and healthcare professionals (HCPs). The aim of this review was to give an overview of currently available evidence around opinions and attitudes towards artificial hydration at the end of life. RECENT FINDING: In total 11 studies reported on opinions towards providing artificial hydration, nine studies reported on attitudes towards the effect of artificial hydration on quality-of-life and four studies towards its effect on survival. Reported percentages of respondents in favour of providing artificial hydration at the end of life varied from 22 to 100% and for nonprovision from 0 to 75%. One-third of the general public has been found to think that artificial hydration improves comfort, while among patients a majority feels it can have a physical or psychological benefit. HCPs were found to be less optimistic: 1-43% thought patients benefit from artificial hydration at the end of life. HCPs mostly agree artificial hydration does not prolong survival, although up to 89% of patients expect it does. SUMMARY: Opinions and attitudes towards the use of artificial hydration at the end of life vary. Communication of this imperative topic in end-of-life care is important for better care and should be research-based.

The cultural context of patient's autonomy and doctor's duty: passive euthanasia and advance directives in Germany and Israel.

The moral discourse surrounding end-of-life (EoL) decisions is highly complex, and a comparison of Germany and Israel can highlight the impact of cultural factors. The comparison shows interesting differences in how patient's autonomy and doctor's duties are morally and legally related to each other with respect to the withholding and withdrawing of medical treatment in EoL situations. Taking the statements of two national expert ethics committees on EoL in Israel and Germany (and their legal outcome) as an example of this discourse, we describe the similarity of their recommendations and then focus on the differences, including the balancing of ethical principles, what is identified as a problem, what social role professionals play, and the influence of history and religion. The comparison seems to show that Israel is more restrictive in relation to Germany, in contrast with previous bioethical studies in the context of the moral and legal discourse regarding the beginning of life, in which Germany was characterized as far more restrictive. We reflect on the ambivalence of the cultural reasons for this difference and its expression in various dissenting views on passive euthanasia and advance directives, and conclude with a comment on the difficulty in classifying either stance as more or less restrictive.

Good life good death according to Christiaan Barnard.

Christiaan Barnard (1922-2002), pioneering heart transplant surgeon, introduced his ideas on euthanasia in a well-written and researched book, Good Life Good Death. A Doctor's Case for Euthanasia and Suicide, published in 1980. His courage in analyzing this topic in a forthright and clear manner is worth reviewing today. In essence, Barnard supported and practiced passive euthanasia (the ending of life by indirect methods, such as stopping of life support) and discussed, but never practiced, active euthanasia (the ending of life by direct means). Barnard believed that "the primary goal of medicine was to alleviate suffering-not merely to prolong life-he argued that advances in modern medical technology demanded that we evaluate our view of death and the handling of terminal illness." Some in the surgical community took issue with Barnard when he publicized his personal views on euthanasia. We discuss Barnard's beliefs and attempt to clarify some misunderstandings regarding this particular controversial area of medicine.

Stopping eating and drinking.

Voluntarily stopping eating and drinking, in which death occurs within one to three weeks of beginning the fast, is increasingly explored in the literature and mainstream media as an option to be discussed with "decisionally capable," suffering patients who want to hasten their dying. The author uses an example from her experience to describe stopping eating and drinking, as well as other clinical practices associated with hastening dying; explores whether this practice can or should be distinguished from suicide; and discusses the ethical and legal implications for nurses.