Characterizing 18 Years of the Death With Dignity Act in Oregon.

Importance: Numerous states have pending physician-aided dying (PAD) legislation. Little research has been done regarding use of PAD, or ways to improve the process and/or results. Objectives: To evaluate results of Oregon PAD, the longest running US program; to disseminate results; and to determine promising PAD research areas. Design, Setting, and Participants: A retrospective observational cohort study of 991 Oregon residents who had prescriptions written as part of the state's Death with Dignity Act. We reviewed publicly available data from Oregon Health Authority reports from 1998 to 2015, and made a supplemental information request to the Oregon Health Authority. Main Outcomes and Measures: Number of deaths from self-administration of lethal medication versus number of prescriptions written. Results: A total of 1545 prescriptions were written, and 991 patients died by using legally prescribed lethal medication. Of the 991 patients, 509 (51.4%) were men and 482 (48.6%) were women. The median age was 71 years (range, 25-102 years). The number of prescriptions written increased annually (from 24 in 1998 to 218 in 2015), and the percentage of prescription recipients dying by this method per year averaged 64%. Of the 991 patients using lethal self-medication, 762 (77%) recipients had cancer, 79 (8%) had amyotrophic lateral sclerosis, 44 (4.5%) had lung disease, 26 (2.6%) had heart disease, and 9 (0.9%) had HIV. Of 991 patients, 52 (5.3%) were sent for psychiatric evaluation to assess competence. Most (953; 96.6%) patients were white and 865 (90.5%) were in hospice care. Most (118, 92.2%) patients had insurance and 708 (71.9%) had at least some college education. Most (94%) died at home. The estimated median time between medication intake and coma was 5 minutes (range, 1-38 minutes); to death it was 25 minutes (range, 1-6240 minutes). Thirty-three (3.3%) patients had known complications. The most common reasons cited for desiring PAD were activities of daily living were not enjoyable (89.7%) and losses of autonomy (91.6%) and dignity (78.7%); inadequate pain control contributed in 25.2% of cases. Conclusions and Relevance: The number of PAD prescriptions written in Oregon has increased annually since legislation enactment. Patients use PAD for reasons related to quality of life, autonomy, and dignity, and rarely for uncontrolled pain. Many questions remain regarding usage and results, making this area suitable for cancer care delivery research.

[Active euthanasia, or assisted suicide?] / Aktív eutanázia vagy asszisztált öngyilkosság?

INTRODUCTION: Both active euthanasia and assisted suicide are legal in The Netherlands, Belgium, Luxemburg and, most recently, in Canada. AIM: Examination of national legislations of countries where both active euthanasia and assisted suicide are legal. The number of accomplished active euthanasia cases and that of assisted suicide cases. METHOD: Analysis of national statistical data. Comparison of statistical data before and after 2010. Comparison of the related practices in the surveyed countries. RESULTS: The number of active euthanasia cases markedly predominates over the number of assisted suicide cases. Cancer is a main reason for active euthanasia, or assisted suicide. In countries with a larger population, the number of active euthanasia cases is higher than that in countries with a smaller population. CONCLUSIONS: Regarding the fact that the applicants for active euthanasia withdraw their requests in a smaller number than the applicants for assisted suicide, patients prefer the choice of active euthanasia. Since the related legislative product is too recent in Canada at present, it may be only presumed that a certain preference will also develop in the related practices in Canada. Orv. Hetil., 2016, 157(40), 1595-1600.

[Active euthanasia in Colombia and assisted suicide in California]. / Aktív eutanázia Kolumbiában és asszisztált öngyilkosság Kaliforniában.

The institution of active euthanasia has been legal in Colombia since 2015. In California, the regulation on physician-assisted suicide will come into effect on January 1, 2016. The legal institution of active euthanasia is not accepted under the law of the United States of America, however, physician-assisted suicide is accepted in an increasing number of member states. The related regulation in Oregon is imitated in other member states. In South America, Colombia is not the first country to legalize active euthanasia: active euthanasia has been legal in Uruguay since 1932. The North American legal tradition markedly differs from the South American one and both are incompatible with the Central European rule of law. In Hungary and in most European Union countries, solely the passive form of euthanasia is legal. In the Benelux countries, the active form of euthanasia is legal because the supranational law of the European Union does not prohibit it. Notwithstanding, European Union law does not prescribe legalization of either the active form of euthanasia, or the physician-assisted suicide.

End-of-life decisions for children under 1†year of age in the Netherlands: decreased frequency of administration of drugs to deliberately hasten death.

OBJECTIVE: To assess whether the frequency of end-of-life decisions for children under 1 year of age in the Netherlands has changed since ultrasound examination around 20 weeks of gestation became routine in 2007 and after a legal provision for deliberately ending the life of a newborn was set up that same year. METHODOLOGY: This was a recurrent nationwide cross-sectional study in the Netherlands. In 2010, a sample of death certificates from children under 1 year of age was derived from the central death registry. All 223 deaths that occurred in a 4-month study period were included. Physicians who had reported a non-sudden death (n=206) were sent a questionnaire on the end-of-life decisions made. 160 questionnaires were returned (response 78%). FINDINGS: In 2010, 63% of all deaths of children under 1 year of age were preceded by an end-of-life decision-a percentage comparable to other times when this study was conducted (1995, 2001, 2005). These end-of-life decisions were mainly decisions to withdraw or withhold potentially life-sustaining treatment. In 2010, the percentage of cases in which drugs were administered with the explicit intention to hasten death was 1%, while in 1995 and 2001, this was 9% and in 2005, this was 8%. DISCUSSION AND CONCLUSION: There has been a reduction of infant deaths that followed administration of drugs with the explicit intention to hasten death. One explanation for this reduction relates to the introduction of routine ultrasound examination around 20 weeks of gestation. In addition, the introduction of legal criteria and a review process for deliberately ending the life of a newborn may have left Dutch physicians with less room to hasten death.

When Physicians Report Having Used Medical Drugs to Deliberately End a Patient's Life: Findings of the "End-of-Life in France" Survey.

CONTEXT: The debate on the decriminalization of active assistance in dying is still a topical issue in many countries where it is regarded as homicide. Despite the prohibition, some physicians say they have used drugs to intentionally end a patient's life. OBJECTIVES: To provide some empirical grounding for the ongoing debate. METHODS: Using data from the End-of-Life in France survey (a representative sample of 15,000 deaths that occurred in December 2009, questionnaires completed anonymously by the physicians who had certified the deaths), we selected all the cases where the physician had used one or more drugs to intentionally end a patient's life and compared the decisions and decision-making process with the conditions imposed by the French law for decisions to withhold or withdraw life-supporting treatments and by the Belgian law on euthanasia. RESULTS: Of the 36 cases analyzed, four situations seemed to be deliberate acts after explicit requests from the patients, and only two seemed to fulfill the eligibility and due care conditions of the Belgian euthanasia law. Decisions made without any discussion with patients were quite common, and we observed inadequate labeling, frequent signs of ambivalence (artificial feeding and hydration not withdrawn, types of drug used), and little interprofessional consultation. Where the patient had requested euthanasia, the emotional burden on the physician was heavy. CONCLUSION: These findings underscore the pressing need for a clarification of the concepts involved among health professionals, patients, and society at large, and better training and support for physicians.

[Assessment of euthanasia request by SCEN physicians]. / Beoordeling van euthanasieverzoek door SCEN-artsen.

OBJECTIVE: To determine how uniformly Support and Consultation on Euthanasia in the Netherlands (SCEN) doctors assess a euthanasia request in patients not in the final stages of a terminal illness. DESIGN: Qualitative research. METHOD: Internal survey among SCEN doctors in the 'SCEN-Drenthe' peer group, who were asked to provide an opinion on the requirements of due care, items a to d, of the Termination of life on request and assisted suicide act (WTL) in three fictitious patients. RESULTS: Sixty assessments were received from 20 SCEN physicians. Half of the reviews were assessed as 'due care requirements not met". 45% of these were for a patient whose request was based on the grounds of a "completed life", 50% for a patient with Alzheimer's, and 55% for a patient with a reduced level of consciousness. Uncertainty about the place of Article 2.2 of the WTL, personal assessment of the unbearable nature of hopeless suffering and the rejection of alternative solutions were responsible for the heterogeneous assessments. CONCLUSION: Uniformity of assessment is important to avoid legal disparity in this patient group. We found no medical or ethical benchmarks for determining the unbearable nature of suffering. A verifying assessment by the SCEN physician can only provide an opinion regarding the presence of hopeless pain that is classified as "unbearable". A negative SCEN assessment undermines a person's sense of justice at a difficult time, while the hopeless suffering may well be accepted as unbearable in comparable cases. Adapting the KNMG "Guidelines on euthanasia for patients in a state of reduced consciousness" so that they are in line with the WTL could also contribute to greater uniformity.

The Groningen Protocol for newborn euthanasia; which way did the slippery slope tilt?

In The Netherlands, neonatal euthanasia has become a legal option and the Groningen Protocol contains an approach to identify situations in which neonatal euthanasia might be appropriate. In the 5 years following the publication of the protocol, neither the prediction that this would be the first step on a slippery slope, nor the prediction of complete transparency and legal control became true. Instead, we experienced a transformation of the healthcare system after antenatal screening policy became a part of antenatal care. This resulted in increased terminations of pregnancy and less euthanasia.

Homicide by poisoning.

By studying the number and method of homicidal poisoning in Miami-Dade County, Florida; New York City, NY; Oakland County, Michigan; and Sweden, we have confirmed that this is an infrequently established crime.Several difficulties come with the detection of homicidal poisonings. Presenting symptoms and signs are often misdiagnosed as natural disease, especially if the crime is committed in a hospital environment, suggesting that an unknown number of homicides go undetected.In the reported cases analyzed, the lethal agent of choice has changed over the years. In earlier years, traditional poisons such as arsenic, cyanide, and parathion were frequently used. Such poisonings are nowadays rare, and instead, narcotics are more commonly detected in victims of this crime.

End-of-life attitudes of intensive care physicians in Poland: results of a national survey.

PURPOSE: This study was designed to assess the ethical attitudes and practices of intensive care physicians regarding life-sustaining treatment in intensive care units (ICUs) in Poland. METHODS: A questionnaire was distributed to intensive care physicians taking part in a national medical congress. Participation in the study was voluntary and anonymous. RESULTS: A total of 400 questionnaires were distributed, of which 217 (54%) were returned completed. Almost all respondents (93%) reported having withheld therapy, and 75% of respondents reported withdrawing therapy. Physicians aged 40 years and over who had no religious affiliation more frequently reported withholding treatment. Only 5% of physicians reported deliberately administering drugs until death ensued. Respondents from large hospitals (more than 400 beds) more easily accepted foregoing life-sustaining therapy in ICU patients. In clinical scenario in which the family demanded the maximum available treatment, physicians reported that they were considerably influenced to modify decisions concerning life-sustaining therapy. CONCLUSIONS: The ethical attitudes of intensive care physicians regarding end-of-life decisions are similar to the opinion presented in other European survey studies. The practice of withholding and withdrawing therapy in ICU patients is common in Poland. Actively shortening life is considered unacceptable. The request of the family even without legal consultation can influence physicians' decisions.

End-of-life decisions in dutch neonatology.

This contribution describes the regulation of end-of-life decisions in neonatology in the Netherlands. An account is given of the process of formulating rules, which includes a report by the Dutch Association for Paediatrics, two Court rulings, a report by a Consultation Group appointed by the Ministry of Health and a professional Protocol regulating deliberate ending of life in neonatology that was subsequently adopted as the regulation of this type of decision-making at the national level. The paper presents Dutch and comparative data on the attitude of the medical profession towards end-of-life decisions in neonatology and the frequency of such decisions in medical practice.

End-of-life practices in palliative care: a cross sectional survey of physician members of the German Society for Palliative Medicine.

OBJECTIVES: To elicit types and frequencies of end-of-life practices by physician members of the German Society for Palliative Medicine. To analyse associations between characteristics of physicians and patients and end-of-life practices with intended hastening of death. DESIGN: Cross-sectional postal survey. MAIN OUTCOME MEASURES: Types and frequencies of end-of-life practices with foreseeable or intended hastening of patients' death. Association between end-of-life practices with hastening of death and predefined characteristics of physicians and patients. RESULTS: Nine hundred and one physicians participated in the study (response rate: 55.8%). There was alleviation of symptoms in 78.1% and limitation of medical treatment with possible life shortening in 69.1% of cases. In 10 cases medication had been administered by the physician (N = 9) or the patient (N = 1) with the intention to hasten death. Patients' best interest and avoidance of possible harm to the patient were reported as reasons for non-involvement of competent patients in decision making. Physicians with added qualification in palliative medicine significantly less frequently reported end-of-life practices with intended hastening of death (p = 0.003). CONCLUSION: Physician members of the German Society for Palliative Medicine perform a broad spectrum of end-of-life practices including intended hastening of death. The findings on patients' non-involvement in decision making warrant further empirical-ethical analysis.

The role of nurses in physician-assisted deaths in Belgium.

BACKGROUND: Belgium's law on euthanasia allows only physicians to perform the act. We investigated the involvement of nurses in the decision-making and in the preparation and administration of life-ending drugs with a patient's explicit request (euthanasia) or without an explicit request. We also examined factors associated with these deaths. METHODS: In 2007, we surveyed 1678 nurses who, in an earlier survey, had reported caring for one or more patients who received a potential life-ending decision within the year before the survey. Eligible nurses were surveyed about their most recent case. RESULTS: The response rate was 76%. Overall, 128 nurses reported having cared for a patient who received euthanasia and 120 for a patient who received life-ending drugs without his or her explicit request. Respectively, 64% (75/117) and 69% (81/118) of these nurses were involved in the physician's decision-making process. More often this entailed an exchange of information on the patient's condition or the patient's or relatives' wishes (45% [34/117] and 51% [41/118]) than sharing in the decision-making (24% [18/117] and 31% [25/118]). The life-ending drugs were administered by the nurse in 12% of the cases of euthanasia, as compared with 45% of the cases of assisted death without an explicit request. In both types of assisted death, the nurses acted on the physician's orders but mostly in the physician's absence. Factors significantly associated with a nurse administering the life-ending drugs included being a male nurse working in a hospital (odds ratio [OR] 40.07, 95% confidence interval [CI] 7.37-217.79) and the patient being over 80 years old (OR 5.57, 95% CI 1.98-15.70). INTERPRETATION: By administering the life-ending drugs in some of the cases of euthanasia, and in almost half of the cases without an explicit request from the patient, the nurses in our study operated beyond the legal margins of their profession.

Influence of the metropolitan environment on end-of-life decisions: A population-based study of end-of-life decision-making in the Brussels metropolitan region and non-metropolitan Flanders.

Research is beginning to show differences between end-of-life care in metropolitan and non-metropolitan areas. Using population-based post-mortem surveys this article compares medical end-of-life decisions in the Brussels metropolitan area and non-metropolitan Flanders (Belgium). In Brussels, administering lethal drugs without an explicit patient request occurred more often, intensification of symptom alleviation and non-treatment decisions less often, and end-of-life treatment was more often aimed at cure or life prolongation, than in non-metropolitan Flanders. This paper argues that these differences in end-of-life decisions are related to characteristics of the metropolitan environment and hence may also apply in other metropolitan regions worldwide. Specific approaches to end-of-life decisions in metropolitan areas need to be considered.

Considerations about hastening death among parents of children who die of cancer.

OBJECTIVES: To estimate the frequency of hastening death discussions, describe current parental endorsement of hastening death and intensive symptom management, and explore whether children's pain influences these views in a sample of parents whose child died of cancer. DESIGN: Cross-sectional survey. SETTING: Two tertiary-care US pediatric institutions. PARTICIPANTS: A total of 141 parents of children who died of cancer (response rate, 64%). OUTCOME MEASURES: Proportion of parents who (1) considered or (2) discussed hastening death during the child's end of life and who endorsed (3) hastening death or (4) intensive symptom management in vignettes portraying children with end-stage cancer. RESULTS: A total of 19 of 141 (13%; 95% confidence interval [CI], 8%-19%) parents considered requesting hastened death for their child and 9% (95% CI, 4%-14%) discussed hastening death; consideration of hastening death tended to increase with an increase in the child's suffering from pain. In retrospect, 34% (95% CI, 26%-42%) of parents reported that they would have considered hastening their child's death had the child been in uncontrollable pain, while 15% or less would consider hastening death for nonphysical suffering. In response to vignettes, 50% (95% CI, 42%-58%) of parents endorsed hastening death while 94% (95% CI, 90%-98%) endorsed intensive pain management. Parents were more likely to endorse hastening death if the vignette involved a child in pain compared with coma (odds ratio, 1.4; 95% CI, 1.1-1.8). CONCLUSIONS: More than 10% of parents considered hastening their child's death; this was more likely if the child was in pain. Attention to pain and suffering and education about intensive symptom management may mitigate consideration of hastening death among parents of children with cancer.

Euthanasia and other end-of-life decisions: a mortality follow-back study in Belgium.

BACKGROUND: This study compares prevalence and types of medical end-of-life decisions between the Dutch-speaking and French-speaking communities of Belgium. This is the first nationwide study that can make these comparisons and the first measurement after implementation of the euthanasia law (2002). METHODS: We performed a mortality follow-back study in 2005-2006. Data were collected via the nationwide Sentinel Network of General Practitioners, an epidemiological surveillance system representative of all Belgian GPs.Weekly, all GPs reported the medical end-of-life decisions among all non-sudden deaths of patients in their practice. We compared the northern Dutch-speaking (60%) and southern French-speaking communities (40%) controlling for population differences. RESULTS: We analysed 1690 non-sudden deaths. An end-of-life decision with possible life-shortening effect was made in 50% of patients in the Dutch-speaking community and 41% of patients in the French-speaking community (OR 1.4; 95%CI, 1.2 to 1.8). Continuous deep sedation until death occurred in 8% and 15% respectively (OR 0.5; 95%CI, 0.4 to 0.7). Community differences regarding the prevalence of euthanasia or physician-assisted suicide were not significant.Community differences were more present among home/care home than among hospital deaths: non-treatment decisions with explicit life-shortening intention were made more often in the Dutch-speaking than in the French-speaking community settings (OR 2.2; 95%CI, 1.2 to 3.9); while continuous deep sedation occurred less often in the Dutch-speaking community settings (OR 0.5; 95%CI, 0.3 to 0.9). CONCLUSION: Even though legal and general healthcare systems are the same for the whole country, there are considerable variations between the communities in type and prevalence of certain end-of-life decisions, even after controlling for population differences.

Trends in the use of opioids at the end of life and the expected effects on hastening death.

The aim of our study was to describe trends in opioid use and perceptions of having hastened the end of life of a patient. In 2005, a questionnaire was sent to 6860 physicians in The Netherlands who had attended a death. The response rate was 78%. In 1995 and 2001 similar studies were done. Physicians less often administered opioids with the intention to hasten death in 2005 (3.1% of the non-sudden deaths) than in 2001 and in 1995 (7% and 10%, respectively). Physicians gave similar dosages of opioids in 2005, 2001, and 1995, but physicians in 2005 less often thought that life was actually shortened than in 2001 and 1995 (37% in 2005, 50% in 2001, and 53% in 1995). Of the physicians in 2005 who did think that the life of the patient was shortened by opioids, 94% did not give higher dosages than were, in their own opinion, required for pain and symptom management. Physicians in 2005 more often took hastening death into account when they gave higher dosages of opioids when the patient experienced more severe symptoms and with female patients. In older patients (>or=80 years), physicians took the hastening of death into account more often, but the actual dosages of opioids were lower. These data indicate that physicians in The Netherlands less often thought that death was hastened by opioids and less often gave opioids, with the intention to hasten death in 2005 than in 2001 and 1995.