Eutanásia Voluntária Ativa, Suicídio Assistido, Ortotanásia e os Cuidados Paliativos: um panorama das discussões no Poder Legislativo Federal Brasileiro / Eutanàsia Voluntària Activa, Suïcidi Assistit, Ortotanàsia i Cures Pal·liatives: un panorama de les discussions en el Poder Legislatiu Federal brasiler / Eutanasia Voluntaria Activa, Suicidio Asistido, Ortotanasia y Cuidados Paliativos: un panorama de las discusiones en el Poder Legislativo Federal brasileño / Voluntary Active Euthanasia, Assisted Suicide, Orthothanasia and Palliative Care: An overview of the discussions in the Brazilian Federal Legislative Power

No âmbito das proposições legislativas brasileiras, buscou-se compreender os desafiose obstáculos no percurso delimitativo das práticas de fim de vida. Analisou-se 193 documentos, desde 1981 até 2020, com base na metodologia hermenêutica-dialética. Evidenciou-se distintas propostas regulamentadoras das práticas de eutanásia e ortotanásia,na relação com os cuidados paliativos. As associações dos termos “cuidados paliativos” e “ortotanásia”, em oposição à “eutanásia/suicídio assistido, revelaram a conflituosa construção de valores que perpassa nossa sociedade. Com a tramitação de projetos relacionados à ortotanásia e eutanásia, compreendemos o sentido das decisões políticas que envolvem as possibilidades de escolhas e liberdade das pessoas, entre o direito à vida e o direito à morte digna. Compreendemos a problemática da legalização da ortotanásia, como forma do poder legislativo se furtar ao debate sobre a eutanásia/suicídio assistido, como alternativa à distanásia e ao sofrimento no processo de morrer.(AU)

En el context de les propostes legislatives brasileres, busquem comprendre els reptes i obstacles en el camí cap a la delimitació de les pràctiques al final de la vida. S'han analitzat 193 documents, des de 1981 fins a 2020, basant-se en la metodologia hermenèutica-dialèctica. S'han evidenciat diferents propostes normatives per a les pràctiques d'eutanàsia i ortotanàsia, en relació als cures pal·liatius. Les associacions dels termes "cures pal·liatius" i "ortotanàsia", en oposició a "eutanàsia/suïcidi assistit", revelen la construcció conflictiva de valors que impregna la nostra societat. Amb la tramitació dels projectes relacionats amb la ortotanàsia i l'eutanàsia, entenem el sentit de les decisions polítiques que implica les possibilitats de tria i llibertat de les persones, entre el dret a la vida i el dret a una mort digna. Comprenguem el problema de la legalització de la ortotanàsia com una forma que el poder legislatiu eviti el debat sobre l'eutanàsia/suïcidi assistit, com a alternativa a la distanàsia i al patiment en el procés de morir.(AU)

En el ámbito de las propuestas legislativas brasileñas, se buscó comprender los desafíos y obstáculos en el camino de la regulación de las prácticas al final de la vida. Se analizaron 193 documentos desde 1981 hasta 2020, utilizando la metodología hermenéutica-dialéctica. Se evidenciaron diferentes propuestas regulatorias relacionadas con la eutanasia y la ortotanasia, en relación con los cuidados paliativos. La asociación de los términos "cuidados paliativos" y "ortotanasia", en contraposición a "eutanasia/suicidio asistido", reveló la conflictiva construcción de valores que atraviesa nuestra sociedad. Con la tramitación de proyectos relacionados con la ortotanasia y la eutanasia, comprendemos el sentido de las decisiones políticas que involucran las posibilidades de elección y libertad de las personas, entre el derecho a la vida y el derecho a una muerte digna. También comprendemos la problemática de la legalización de la ortotanasia como una forma de que el poder legislativo evite el debate sobre la eutanasia/suicidio asistido, como una alternativa a la distanasia y al sufrimiento en el proceso de morir.(AU)

Within the scope of Brazilian legislative proposals, we sought to understand the challenges and obstacles in the delimiting path of end-of-life practices. 193 documents were analyzed, from 1981 to 2020, based on the hermeneutic-dialectical methodology. Different regulatory proposals for the practices of euthanasia and orthothanasia, in relation to palliative care, were evidenced. The associations of the terms “palliative care” and “orthothanasia”, as opposed to “euthanasia/assisted suicide, revealed the conflicting construction of values that permeates our society. With the processing of projects related to orthothanasia and euthanasia, we understand the meaning of political decisions that involve the possibilities of choices and freedom of people, between the right to life and the right to a dignified death. We understand the problem of legalizing orthothanasia as a way for the legislative power to evade the debate on euthanasia/assisted suicide, as an alternative to dysthanasia and suffering in the dying process.(AU)

A Systematic Review of Stakeholder Perspectives of Dignity and Assisted Dying.

INTRODUCTION: The debate on assisted dying and its components, euthanasia and physician-assisted suicide has evolved with the emergence of the right to dignity and the wish to hasten death (WTHD). Whilst shaped by local legal and sociocultural considerations, appreciation of how patients, healthcare professionals and lawmakers relate notions of dignity to self-concepts of personhood and the desire for assisted dying will better inform and direct support of patients. METHODS: Guided by the Systematic Evidence Based Approach, a systematic scoping review (SSR in SEBA) on perspectives of dignity, WTHD and personhood featured in PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Scopus databases and four key Palliative Care journals was conducted. The review hinged on the following questions: "what is the relationship between dignity and the wish to hasten death (WTHD) in the assisted dying debate?", "how is dignity conceptualised by patients with WTHD?" and "what are prevailing perspectives on the role of assisted dying in maintaining a dying patient's dignity?" RESULTS: 6947 abstracts were identified, 663 full text articles reviewed, and 88 articles included. The four domains identified include 1) concepts of dignity through the lens of the Ring Theory of Personhood (RToP) including their various definitions and descriptions; 2) the relationship between dignity, WTHD and assisted dying with loss of dignity and autonomy foregrounded; 3) stakeholder perspectives for and against assisted dying including those of patient, healthcare provider and lawmaker; and 4) other dignity-conserving measures as alternatives to assisted dying. CONCLUSION: Concepts of dignity constantly evolve throughout the patient's end of life journey. Understanding when and how these concepts of personhood change and trigger the fear of a loss of dignity or intractable suffering could direct timely, individualised and appropriate person-centred dignity conserving measures. We believe an RToP-based tool could fulfil this role and further study into the design of this tool is planned.

Ethical judgment in assessing requests for medical assistance in dying in Canada and Quebec: What can we learn from other jurisdictions?

This paper concerns the ethical judgment that lies at the heart of assessing requests for Medical Assistance in Dying (MAID) in Canada and Quebec, namely is it ethically right to help the person requesting assistance to end his or her life? We address situations in which making this judgment may be challenging despite the person fulfilling legal eligibility requirements. Using three clinical cases that are challenging by virtue of the legal requirement that a person experience intolerable suffering we explore this issue. We review practice guidance provided to providers and assessors in six jurisdictions and discuss potential resources to inform the ethical judgments involved in MAID assessments.

The End of Life Choice Act: a proposed implementation and research agenda.

AIM: This article outlines the End of Life Choice Act 2019. It highlights some of the key implementation issues to ensure the system operates safely and equitably after the Act comes into force. It also identifies priorities for research to ensure issues are detected and provision of assisted dying (AD) is monitored. METHOD: We reviewed the End of Life Choice Act, assisted dying implementation literature and governmental reports. RESULTS: Effective system implementation depends on infrastructure, oversight and funding. In terms of service provision, we make recommendations about training for all health practitioners and providing practitioners; the nuances of discussing the "wish to hasten death"; conscientious objection; cultural safety for Maori; and minimising the complexity of delivering assisted dying practice. Structured research is needed to understand how the assisted dying system is operating. CONCLUSION: This article contributes by identifying core issues for practitioners, patients and policymakers. Implementation is an ongoing process that continues after the Act starts. Data are required to know whether access is equitable, who is choosing to make use of the law, whether providers are well informed and whether the safeguards are working as intended. The implications of how the Act is implemented are significant for patients, whanau, health professionals and society.

Eutanasia: ¿es esta la ley que necesitamos? / Euthanasia: is this the law we need?

La Ley de Eutanasia española introduce un nuevo derecho que se incorpora a la cartera de servicios del sistema sanitario, como una prestación cuya aplicación se garantiza en el plazo de 40 días. Desde la experiencia clínica se argumenta que, sin el derecho efectivo a unos cuidados paliativos de calidad, y con el actual déficit en las ayudas a la dependencia, esta ley puede ser un mensaje coactivo para aquellas personas especialmente frágiles y dependientes, que se sientan como una pesada carga para su familia y para la sociedad.Se razona de qué modo fundamentar el derecho a morir en la dignidad de la persona, puede tener repercusiones sociales inesperadas.El texto normativo muestra debilidades propias de una ley apresurada y sin apoyo de órganos consultivos. Hay cuestiones pendientes de aclarar en su aplicación dentro del contexto de la medicina de familia. Se concluye que esta nueva norma planteará más problemas de los que pretende resolver.(AU)

The Spanish Euthanasia Law introduces a new right that is added to the portfolio of services provided by the Spanish health system and whose application is guaranteed within a period of 40 days. From the perspective of clinical experience, it is argued that without the effective right to quality palliative care and given the current shortcomings in dependant care, this law may send a threatening message to particularly fragile and dependant individuals that will lead to them feeling like a burden to their families and society.It is reasoned that basing the right to die on the dignity of the individual may have unexpected social repercussions.The text of the law presents the flaws of having been written hastily and without the support of advisory entities. There are issues that require clarification with regard to the application of euthanasia within the context of general practice. The conclusion is that this new law will pose more problems of the type it aims to resolve.(AU)

Assessment of capacity to give informed consent for medical assistance in dying: a qualitative study of clinicians' experience.

BACKGROUND: Under the Canadian Criminal Code, medical assistance in dying (MAiD) requires that patients give informed consent and that their ability to consent is assessed by 2 clinicians. In this study, we intended to understand how Canadian clinicians assessed capacity in people requesting MAiD. METHODS: This qualitative study used interviews conducted between August 2019 and February 2020, by phone, video and email, to explore how clinicians assessed capacity in people requesting MAiD, what challenges they had encountered and what tools they used. The participants were recruited from provider mailing listserves of the Canadian Association of MAiD Assessors and Providers and Aide médicale à mourir. Interviews were audio-recorded and transcribed verbatim. The research team met to review transcripts and explore themes as they emerged in an iterative manner. We used abductive reasoning for thematic analysis and coding, and continued to discuss until we reached consensus. RESULTS: The 20 participants worked in 5 of 10 provinces across Canada, represented different specialties and had experience assessing a total of 2410 patients requesting MAiD. The main theme was that, for most assessments, the participants used the conversation about how the patient had come to choose MAiD to get the information they needed. When the participants used formal capacity assessment tools, this was mostly for meticulous documentation, and they rarely asked for psychiatric consults. The participants described how they approached assessing cases of nonverbal patients and other challenging cases, using techniques such as ensuring a quiet environment and adequate hearing aids, and using questions requiring only "yes" or "no" as an answer. INTERPRETATION: The participants were comfortable doing MAiD assessments and used their clinical judgment and experience to assess capacity in ways similar to other clinical practices. The findings of this study suggest that experienced MAiD assessors do not routinely require formal capacity assessments or tools to assess capacity in patients requesting MAiD.