Assessment of patient decision-making capacity in the context of voluntary euthanasia for psychic suffering caused by psychiatric disorders: a qualitative study of approaches among Belgian physicians.

OBJECTIVE: In Belgium, people with an incurable psychiatric disorder can file a request for euthanasia claiming unbearable psychic suffering. For the request to be accepted, it has to meet stringent legal criteria. One of the requirements is that the patient possesses decision-making capacity. The patient's decision-making capacity is assessed by physicians.The objective of our study is to provide insight in the assessment of decision-making capacity in the context of euthanasia for patients with psychic suffering caused by a psychiatric disorder. METHOD: Twenty-two semistructured interviews with psychiatrists and neurologists were analysed with NVivo, a qualitative analysis software to code and organise transcribed data. RESULTS: Different views and approaches regarding decision-making capacity in the context of euthanasia emerged from the data.Most of the physicians have some knowledge of the cognitive ability approach on decision-making capacity. According to this approach, four abilities constitute decision-making capacity: communication, understanding, appreciation and reasoning. We observed differences in the way these abilities are valued in relation to competence. Some physicians take additional elements into consideration when assessing decision-making capacity.Physicians acquired their knowledge on the subject in many different ways. Most of the physicians reported that decision-making capacity was not part of their training. CONCLUSION: We conclude that physicians assess decision-making capacity in different ways and that personal values and beliefs influence their approach. As such, a common approach in assessing the decision-making capacity of a patient among the interviewed physicians is lacking. Less arbitrariness could be obtained by consistently implementing the cognitive ability approach.

Nationwide survey to evaluate the decision-making process in euthanasia requests in Belgium: do specifically trained 2nd physicians improve quality of consultation?

BACKGROUND: Following the 2002 enactment of the Belgian law on euthanasia, which requires the consultation of an independent second physician before proceeding with euthanasia, the Life End Information Forum (LEIF) was founded which provides specifically trained physicians who can act as mandatory consultants in euthanasia requests. This study assesses quality of consultations in Flanders and Brussels and compares these between LEIF and non-LEIF consultants. METHODS: A questionnaire was sent in 2009 to a random sample of 3,006 physicians in Belgium from specialties likely involved in the care of dying patients. Several questions about the last euthanasia request of one of their patients were asked. As LEIF serves the Flemish speaking community (i.e. region of Flanders and the bilingual Brussels Capital Region) and no similar counterpart is present in Wallonia, analyses were limited to Flemish speaking physicians in Flanders and Brussels. RESULTS: Response was 34%. Of the 244 physicians who indicated having received a euthanasia request seventy percent consulted a second physician in their last request; in 30% this was with a LEIF physician. Compared to non-LEIF physicians, LEIF physicians were more often not a colleague (69% vs 42%) and not a co-attending physician (89% vs 66%). They tended to more often discuss the request with the attending physician (100% vs 95%) and with the family (76% vs 69%), and also more frequently helped the attending physician with performing euthanasia (44% vs 24%). No significant differences were found in the extent to which they talked to the patient (96% vs 93%) and examined the patient file (94% vs 97%). CONCLUSION: In cases of explicit euthanasia requests in Belgium, the consultation procedure of another physician by the attending physician is not optimal and can be improved. Training and putting at disposal consultants through forums such as LEIF seems able to improve this situation. Adding stipulations in the law about the necessary competencies and tasks of consulting physicians may additionally incite improvement. Irrespective of whether euthanasia is a legal practice within a country, similar services may prove useful to also improve quality of consultations in various other difficult end-of-life decision-making situations.

Utility of Islet Cell Preparations From Donor Pancreases After Euthanasia.

Patients fulfilling criteria for euthanasia can choose to donate their organs after circulatory death [donors after euthanasia (DCD V)]. This study assesses the outcome of islet cell isolation from DCD V pancreases. A procedure for DCD V procurement provided 13 pancreases preserved in Institut Georges Lopez-1 preservation solution and following acirculatory warm ischemia time under 10 minutes. Islet cell isolation outcomes are compared with those from reference donors after brain death (DBD, n = 234) and a cohort of donors after controlled circulatory death (DCD III, n = 29) procured under the same conditions. Islet cell isolation from DCD V organs resulted in better in vitro outcome than for selected DCD III or reference DBD organs. A 50% higher average beta cell number before and after culture and a higher average beta cell purity (35% vs 24% and 25%) was observed, which led to more frequent selection for our clinical protocol (77% of isolates vs 50%). The functional capacity of a DCD V islet cell preparation was illustrated by its in vivo effect following intraportal transplantation in a type 1 diabetes patient: injection of 2 million beta cells/kg body weight (1,900 IEQ/kg body weight) at 39% insulin purity resulted in an implant with functional beta cell mass that represented 30% of that in non-diabetic controls. In conclusion, this study describes procurement and preservation conditions for donor organs after euthanasia, which allow preparation of cultured islet cells, that more frequently meet criteria for clinical use than those from DBD or DCD III organs.

Characteristics of referral to a multidisciplinary palliative home care team.

INTRODUCTION: Until now, in Belgium at least, no scientific information has been available about which patients are referred to multidisciplinary palliative home care teams (MHCT) and by which caregivers, nor about timing of referral and factors associated with it. METHODS: A prospective cohort study was carried out during a nine-month period in the oldest Flemish MHCT, and included all patients for whom a palliative care trajectory had been initiated. RESULTS: In total, 325 patients (54% male, mean age 71 years, 83% cancer patients) were referred: 25% by their GP, 24% by hospital social workers, and 22% by the patient's family. Median timing of referral was 26 days (IQR 8-78) before death. Patients of 75 years or older were more likely to have been referred later by comparison with younger patients. DISCUSSION: Timely referral to a MHCT seems to be difficult and not equal for all patients. Referral timing varies largely by age groups and diseases.

Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study.

OBJECTIVES: To identify patterns in euthanasia requests and practices relating to psychiatric patients; to generate recommendations for future research. DESIGN: Retrospective analysis of data obtained through medical file review. SETTING: Outpatient psychiatric clinical setting in the Dutch-speaking region of Belgium, between October 2007 and December 2011; follow-up at the end of December 2012. PARTICIPANTS: 100 consecutive psychiatric patients requesting euthanasia based on psychological suffering associated with psychiatric disorders (77 women, 23 men; mean age 47 years; age range 21-80 years). MAIN OUTCOME MEASURES: Patient sociodemographic characteristics; diagnoses; decisions on euthanasia requests; circumstances of euthanasia procedures; patient outcomes at follow-up. RESULTS: Most patients had been referred for psychiatric counselling by their physician (n=55) or by LEIF (Life End Information Forum) (n=36). 90 patients had >1 disorder; the most frequent diagnoses were depression (n=58) and personality disorder (n=50). 38 patients required further testing and/or treatment, including 13 specifically tested for autism spectrum disorder (ASD); 12 received an ASD diagnosis (all Asperger syndrome). In total, 48 of the euthanasia requests were accepted and 35 were carried out. Of the 13 remaining patients whose requests were accepted, 8 postponed or cancelled the procedure, because simply having this option gave them enough peace of mind to continue living. In December 2012, 43 patients had died, including 35 by euthanasia; others died by suicide (6), palliative sedation (1) and anorexia nervosa (1). CONCLUSIONS: Depression and personality disorders are the most common diagnoses in psychiatric patients requesting euthanasia, with Asperger syndrome representing a neglected disease burden. Further research is needed, especially prospective quantitative and qualitative studies, to obtain a better understanding of patients with psychiatric disorders who request euthanasia due to unbearable psychological suffering.

Questions and answers on the Belgian model of integral end-of-life care: experiment? Prototype? : "Eu-euthanasia": the close historical, and evidently synergistic, relationship between palliative care and euthanasia in Belgium: an interview with a doctor involved in the early development of both and two of his successors.

This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan Bernheim, independent from but together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors.

Implementation of a service for physicians' consultation and information in euthanasia requests in Belgium.

AIM: To study the implementation of LEIF, the consultation service which provides access to specially trained physicians to act as the legally required second physician in requests for euthanasia in Flanders and Brussels, Belgium, the use of which has been to shown to be beneficial to the careful practice of euthanasia. METHOD: A representative sample of 3006 Belgian physicians from the area where LEIF is active received a questionnaire investigating their attitude and practice regarding euthanasia, asking about their knowledge of LEIF, their attitude towards the service, their use of the service and their intentions regarding its future use. FINDINGS: Seventy-eight per cent of physicians knew about the existence of the organization, 90% felt supported by the idea of being able to consult a LEIF physician and 90% intended to use LEIF in the future. Only 35% of those who had received a euthanasia request since LEIF became active had made use of LEIF. Awareness, use and intended use of LEIF were lower among specific groups of physicians (e.g. specialists). Positive attitudes towards consultation and training were positively associated with future use of LEIF. CONCLUSION: Implementation can be considered successful but LEIF should continue promoting its services as widely as possible, with specific attention paid to specialists.

Consulting a trained physician when considering a request for euthanasia: an evaluation of the process in flanders and the Netherlands.

In Belgium and the Netherlands, consultation of a second independent physician by the attending physician is mandatory in euthanasia cases. In both countries, specialized consultation services have been established to provide physicians trained for that purpose. This retrospective study describes and compares the quality of consultation of both services based on surveys of attending physicians and those providing the consultation (consultants). While Dutch consultants discussed certain subjects, for example, alternative curative or palliative treatment more often with the attending physician than Belgian consultants, both usually discussed those subjects considered necessary for a quality consultation and were independent from patient and attending physician. Over 90% of attending physicians in both countries evaluated the consultant's knowledge of palliative care, patient's disease, and judicial procedure, and their communication skills, as sufficient. Consultation with specialized consultation services seems to promote quality of euthanasia consultations.

Role and involvement of life end information forum physicians in euthanasia and other end-of-life care decisions in Flanders, Belgium.

OBJECTIVE: To describe role and involvement of Life End Information Forum (LEIF) physicians in end-of-life care decisions and euthanasia in Flanders. STUDY DESIGN: All 132 LEIF physicians in Belgium received a questionnaire inquiring about their activities in the past year, and their end-of-life care training and experience. PRINCIPAL FINDINGS: Response rate was 75 percent. Most respondents followed substantive training in end-of-life care. In 1 year, LEIF physicians were contacted 612 times for consultations in end-of-life decisions, of which 355 concerned euthanasia requests eventually resulting in 221 euthanasia cases. LEIF physicians also gave information about various end-of-life issues (including palliative care) to patients and colleagues. CONCLUSIONS: LEIF physicians provide a forum for information and advice for physicians and patients. A similar health service providing support to physicians for all end-of-life decisions could also be beneficial for countries without a euthanasia law.