Life Fatigue: A Critical Analysis.

INTRODUCTION: In recent years, euthanasia has been decriminalized or legalized in several countries. The debate on whether to legalize such a practice is open in many places and is a topic that arouses great controversy. Euthanasia has been presented as a response to situations of advanced, incurable, or irreversible disease, or situations that cause intolerable suffering to the person. However, in recent years, the claim has been asserted that this practice does not have to be associated with such situations. It may happen that a person wants to die and asks for help to do so, even if they are not in a specific clinical situation (pathology or condition) but are experiencing advanced age or present 'vital fatigue'. AIM: The objective of this article is to critically analyse the concept 'vital fatigue': define its meaning, its characteristics, its causes, and its consequences in the debate around euthanasia. To do this, a critical review of the main discussions and arguments present in the literature is made. CONCLUSIONS: It is concluded that vital fatigue can be understood as a product or manifestation of an individualistic and productivistic vision of the human being, in which its relational nature and intrinsic value remain in the background. The loss of the meaning of life also influences him. Therefore, in the face of this phenomenon, the most guaranteeing and ethical option is -we believe-accompaniment and holistic care of the person that allows the causal factors to be modulated, without the need to resort to euthanasia.

The debate rages on: physician-assisted suicide in an ethical light.

The British Medical Association and some Royal Colleges have recently changed their stance on physician-assisted suicide from 'opposed' to forms of 'neutral'. The Royal College of Anaesthetists will poll members soon on whether to follow suit. Elsewhere neutrality amongst professional bodies has preceded legalisation of physician-assisted suicide. We examine the arguments relevant to the anaesthesia community and its potential impact in the UK.

"How long is life worth living for the horse?" A focus group study on how Austrian equine stakeholders assess quality of life for chronically ill or old horses.

BACKGROUND: Quality of life (QoL) provides a comprehensive concept underpinning veterinary decision-making that encompasses factors beyond physical health. It becomes particularly pertinent when seeking responsible choices for chronically ill or old horses that emphasise their well-being and a good QoL over the extension of life. How different stakeholders use the concept of QoL is highly relevant when considering the complexity of these decisions in real-life situations. METHODS: Seven focus group discussions (N = 39) were conducted to gain insights into how stakeholders assess and use equine QoL in veterinary care decisions for chronically ill and/or old horses. The discussions included horse owners (n = 17), equine veterinarians (n = 7), veterinary officers (n = 6), farriers (n = 4), and horse caregivers (n = 5). The combination of deductive and inductive qualitative content analysis of the group discussions focused on identifying both similarities and differences in the views of these groups regarding QoL for old and/or chronically ill horses. RESULTS: Findings show agreement about two issues: the importance of the individuality of the horse for assessing QoL and the relevance of QoL in making decisions about veterinary interventions. We identified differences between the groups with respect to three issues: the time required to assess QoL, stakeholders' contributions to QoL assessments, and challenges resulting from those contributions. While owners and caregivers of horses emphasised their knowledge of a horse and the relevance of the time they spend with their horse, the veterinarians in the study focused on the differences between their own QoL assessments and those of horse owners. In response to challenges regarding QoL assessments and decision-making, stakeholders described different strategies such as drawing comparisons to human experiences. CONCLUSIONS: Differences between stakeholders regarding equine QoL assessments contribute to challenges when making decisions about the care of chronically ill or old horses. The results of this study suggest that individual and collaborative reflection about a horse's QoL should be encouraged, for example by developing practicable QoL assessment tools that support relevant stakeholders in this process.

Euthanasia of animals - association with veterinarians' suicidal thoughts and attitudes towards assisted dying in humans: a nationwide cross-sectional survey (the NORVET study).

BACKGROUND: Veterinarians are an occupational group with an increased suicide risk. Euthanasing animals may influence both veterinarians' views on assisted dying in humans and their suicide risk. We investigated (I) attitudes towards assisted dying, (II) whether the field of work and the frequency of euthanasing animals were associated with positive attitudes towards human euthanasia, and (III) whether frequently euthanasing animals was associated with serious suicidal thoughts. METHODS: We conducted a nationwide cross-sectional study among veterinarians in Norway (response rate: 75%). Logistic regression models were used to calculate the odds ratios for both positive attitudes towards human euthanasia and serious suicidal thoughts. The analyses were adjusted for socio-demographic and work-related factors. RESULTS: Fifty-five percent of the veterinarians agreed that euthanasia should be permitted for humans with a fatal disease and short life expectancy. Working with companion animals was independently associated with positive attitudes towards human euthanasia (OR = 1.66 (95% CI: 1.23-2.23)), while veterinarians' frequency of euthanasing animals was not. Frequency of euthanasing animals was independently associated with serious suicidal thoughts, OR = 2.56 (95% CI: 1.35-4.87). CONCLUSIONS: Veterinarians' attitudes towards assisted dying in humans did not differ from those of the general population. Veterinarians' frequency of euthanasing animals was not associated with positive attitudes towards euthanasia in humans. However, veterinarians working in companion animal practices were more likely to have positive attitudes towards euthanasia in humans. Moreover, euthanising animals five times or more a week was associated with serious suicidal thoughts. We need more research to infer about causality in these findings.

Maybe for unbearable suffering: Diverse racial, ethnic and cultural perspectives of assisted dying. A scoping review.

BACKGROUND: Assisted dying, also commonly known as euthanasia and physician-assisted suicide, is legal in many countries. Interest in assisted dying is growing due to evolving societal understandings of a good death and a desire for choice. Ethico-legal perspectives are well-known, but as societies become more heterogenous, a greater understanding of the perspectives of people from diverse racial, ethnic, and cultural backgrounds is needed. AIM: To explore perspectives of people from diverse racial, ethnic and cultural backgrounds about assisted dying. DESIGN: Scoping review with narrative synthesis. The protocol was registered with Open Science Framework. DATA SOURCES: Medline, CINAHL Complete, PsycINFO and ProQuest Dissertations & Theses Global were searched from inception to May 2023. Citations were independently assessed against inclusion and exclusion criteria. RESULTS: Of the 17 included studies, perspectives of assisted dying were presented according to religion, religiosity, spirituality, race, ethnicity and ancestry. Perspectives were diverse, presenting more as a spectrum, with multiple intersections and interconnections. Support and/or opposition for assisted dying differed according to cultural attributes, but even amongst those with similar cultural attributes, perspectives differed according to life experiences and notions of suffering. CONCLUSION: Perspectives on assisted dying are dynamic and evolving. Even where assisted dying is legalised, individual's cultural attributes contribute to unique perspectives of assisted dying as an end-of-life option. Thus, understanding a person's culture, beliefs, expectations and choices in illness, treatment goals and care is fundamental, extending beyond what may be already considered as part of clinician-patient care relationships and routine advance care planning.

A rebuttal on externalism.

In a recent paper, I argued that an externalist understanding of mental disorder from the philosophy of psychiatry presents an ethical challenge to the practice of medical assistance in dying (MAiD) for psychiatric illness, because it highlights the ways in which the suffering associated with psychiatric illness is sustained by features of the external environment wherein the person is embedded, including social barriers and injustices. In a response to my paper, Harry Hudson argues that addressing social inequality lacks relevance to the immediate permissibility of psychiatric MAiD and that the issue of psychiatric MAiD should be informed by 'pragmatic politics' rather than by 'obfuscatory philosophy'. Herein, I contend that Hudson's response misconstrues my position and ascribes to me views I neither express nor endorse. My paper does not claim that psychiatric MAiD should be denied to people who are presently in intolerable distress. Rather, it suggests that the provision of psychiatric MAiD comes along with social responsibilities of the state to attend to the barriers and injustices that sustain and exacerbate psychiatric illness, as well as ethical responsibilities of clinicians to consider a wider range of presently available psychological and social interventions which may have been neglected under a traditional internalist approach.

Why the irremediability requirement is not sufficient to deny psychiatric euthanasia for patients with treatment-resistant depression.

Treatment-resistant depression (TRD) holds centrality in many debates regarding psychiatric euthanasia. Among the strongest reasons cited by opponents of psychiatric euthanasia is the uncertainty behind the irremediability of psychiatric illnesses. According to this argument, conditions that cannot be considered irremediable imply that there are possible remedies that remain for the condition. If there are possible remedies that remain for the condition, then patients with that condition cannot be considered for access to euthanasia. I call this the irremediability requirement (IR). I argue that patients with TRD can, indeed, meet the operationalisation of irremediability in the IR. This is because the irremediability it asks for is not some global or absolute irremediability, but rather a present irremediability based on the current state of medical science. I show this by considering irremediability relating to (1) possible future treatments and (2) not trying presently available alternative treatments. I extend Schuklenk nd van de Vathorst's argument from parity to terminal malignancies, to show that (1) is an unreasonable expectation for all cases of euthanasia. Taking (2) as a more serious opponent to psychiatric euthanasia, I show how the IR, based on how it is presently operationalised, can be realistically applied to cases of TRD. I do this by further developing Tully's argument on broad-sense treatment resistance with the robust empirical data from the STAR*D trials. If my argument from Tully's is valid, then we have reasons to, again, seek parity between the operationalisations of irremediability in terminal malignancies and TRD.

Words matter: 'enduring intolerable suffering' and the provider-side peril of Medical Assistance in Dying in Canada.

Enduring intolerable suffering, an essential eligibility criterion in Medical Assistance in Dying (MAiD) in Canada and elsewhere, is a contradiction in terms, in that suffering must be tolerable to be endured. Cases of people who were approved for MAiD but who elected to die naturally, thus tolerating their suffering, bear out the unreliability of this central safeguard. The clinical assessment of intolerable suffering may be strengthened by adopting a definition of intolerable suffering centred on clinically evidenced physical and psychological decompensation. This argument also raises important questions about the risks of MAiD clinicians subjectively defining, approving and providing MAiD in ways that deviate from accepted legal and clinical concepts and ethics. Examples show some prolific clinicians describe MAiD in terminology that differs from such norms, as a personal mission, as personally pleasurable, and as a rights-based service. These alternative views are explored for their risks in assessing and providing MAiD for intolerable suffering. This further demonstrates the need for conceptual clarity in legislation, improved vetting and monitoring of clinicians, and a different assessment process to protect patients and clinicians.

Medical oncologist perceptions and willingness to participate in voluntary assisted dying in South Australia.

This study surveyed South Australian medical oncologists to capture their perceptions, willingness to participate and perceived barriers and motivations to participation in voluntary assisted dying (VAD) activities. Approximately 70% of surveyed medical oncologists reported familiarity with VAD legislation. Less than half of physicians (39.1%) reported willingness to participate in any VAD activities, and the rate of conscientious objection was 22%. The top barriers to participation were lack of time and uncertainty given no prior experience. These results demonstrate both a low rate of conscientious objection and a low rate of willingness to participate at the point of VAD implementation in South Australia, and identify barriers to participation that are largely logistical.

The association between social connectedness and euthanasia and assisted suicide and related constructs: systematic review.

BACKGROUND: Euthanasia and assisted suicide (EAS) requests are common in countries where they are legal. Loneliness and social isolation are modifiable risk factors for mental illness and suicidal behaviour and are common in terminal illness. Our objective was to summarise available literature to clarify whether these and related measures of social connectedness might contribute to requests for EAS. METHODS: We conducted a pre-registered (PROSPERO CRD42019160508) systematic review and narrative synthesis of quantitative literature investigating associations between social connectedness and a) requested/actual EAS, b) attitudes towards EAS, and c) a desire for hastened death (DHD) by searching six databases (PsycINFO, MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar) from inception to November 2022, rating eligible peer-reviewed, empirical studies using the QATSO quality assessment tool. RESULTS: We identified 37 eligible studies that investigated associations with a) requested/actual EAS (n = 9), b) attitudes to EAS (n = 16), and c) DHD (n = 14), with limited overlap, including 17,359 participants. The majority (62%) were rated at medium/high risk of bias. Focussing our narrative synthesis on the more methodologically sound studies, we found no evidence to support an association between different constructs of social connectedness and requested or actual EAS, and very little evidence to support an association with attitudes to EAS or an association with DHD. CONCLUSIONS: Our findings for all age groups are consistent with a those of a previous systematic review focussed on older adults and suggest that poor social connectedness is not a clear risk factor for EAS or for measures more distally related to EAS. However, we acknowledge low study quality in some studies in relation to sampling, unvalidated exposure/outcome measures, cross-sectional design, unadjusted analyses, and multiple testing. Clinical assessment should focus on modifying established risk factors for suicide and EAS, such as hopelessness and depression, as well as improving any distressing aspects of social disconnectedness to improve quality of life. FUNDING: UKRI, NIHR.

Euthanasia, consensual homicide, and refusal of treatment.

Consensual homicide remains a crime in jurisdictions where active voluntary euthanasia has been legalized. At the same time, both jurisdictions, in which euthanasia is legal and those in which it is not, recognize that all patients (whether severely ill or not) have the right to refuse or withdraw medical treatment (including life-saving treatment). In this paper, I focus on the tensions between these three norms (the permission of active euthanasia, the permission to reject life-saving treatment, and the prohibition of consensual homicide), assuming a justification of euthanasia based on the right to (personal) autonomy. I argue that the best way to provide a coherent account of these norms is to claim that patients have two distinct rights: the right to autonomy and the right to bodily integrity. This solution has some relevant implications for the discussion of the legalization of active euthanasia.

Best to possibly not be: A prudential argument for antinatalism.

This article starts by examining the present state of death ethics by attending to the euthanasia debate. Given that voluntary active euthanasia has seen strong support in the academic community, insights on the choiceworthiness of continued existence may be derived. Having derived cases of choiceworthy nonexistence (which I refer to as choiceworthy nonexistence [CNE] cases), I extend these intuitions to lives not worth starting, or choiceworthy nonexistence for potential people (which I refer to as foetal-CNE, or fCNE cases). Although I depart from Benatarian antinatalism by rejecting Benatar's claim that all existence is necessarily a harm, I posit a weaker argument that all existence is likely a harm since we cannot know until later in life if an existence is a harm. If I am right, then we have prudential reasons not to bear children, since they are more likely to suffer in lives not worth living than not.

Euthanasia in detention and the ethics of caring solidarity: A case study of the 'Tarragona Gunman'.

Almost a year after the enactment of the law regulating euthanasia in Spain, public opinion was shocked to learn that a defendant in criminal proceedings obtained medical assistance in dying following injuries sustained in an exchange of gunfire with the police after having committed a series of severe crimes. Although there are very few cases in the world where prisoners have received euthanasia, the one we will discuss in this article is the only known case where both the public prosecutor's office and the private prosecutors judicially opposed the defendant's euthanasia. This article aims to offer a new perspective on the ethical legitimacy of detainees' access to euthanasia: the ethics of caring solidarity. To do this, we will first place the case in its legal context. Subsequently, we will address the two main arguments proposed in the literature to justify euthanasia in detention: respect for the autonomy of the detainee and the principle of equivalence of care. Finally, after having identified serious shortcomings in both arguments, we will argue that the perspective of caring solidarity offers a better ethical basis for people in detention's access to euthanasia.

Acceptance of euthanasia by students of selected study disciplines at universities in Lublin, Poland.

BACKGROUND: In the context of discussions between supporters and opponents of euthanasia, and legal regulations regarding this type of practices, the attitude of young people with respect to this phenomenon is a very interesting issue. According to Polish law, euthanasia is prohibited. The aim of this study was to determine the degree of acceptance of euthanasia among students from Polish universities across three different fields of study: psychology, medicine, and economic-technical disciplines, and to identify the factors associated with the acceptance of this phenomenon. METHODS: The study included 627 persons studying in Lublin, Poland: medicine (280), psychology (170), and economic-technical studies (177). The study was conducted as a survey using questionnaire containing items concerning students' attitudes towards euthanasia. The analysis of the collected data was conducted using the SPSS software (version 29) with the following methods: Chi2, Student's t-test, Phi test, Cramer's V test, Kolmogorov-Smirnov test, one-way ANOVA with Dunnett's post hoc test, linear regression analysis, and categorical regression analysis using optimal scaling (CATREG). RESULTS: Nearly half of the students participating in the study (45.9%) rated the practice of euthanasia as decidedly negative. The highest number of strongly negative evaluations was found among psychology students, and the least among students of economic-technical disciplines. The level of acceptance of euthanasia is significantly associated with religious involvement and studying psychology. Being religious and being a psychology student both contribute to lower acceptance of euthanasia and a lower willingness to consent to euthanasia. Consent to euthanasia is more commonly declared by individuals with experience of living with elderly people. CONCLUSIONS: Although nearly half of the respondents expressed a negative attitude towards euthanasia, considering the secularization process among Polish youth, it can be assumed that the level of acceptance of euthanasia in this social group will increase. The lower level of acceptance of euthanasia among psychology and medical students compared to students of economic-technical disciplines suggests that the curricula of these studies present alternative solutions to the problems of terminally ill patients other than euthanasia.

Facing a request for assisted death - views of Finnish physicians, a mixed method study.

BACKGROUND: Assisted death, including euthanasia and physician-assisted suicide (PAS), is under debate worldwide, and these practices are adopted in many Western countries. Physicians' attitudes toward assisted death vary across the globe, but little is known about physicians' actual reactions when facing a request for assisted death. There is a clear gap in evidence on how physicians act and respond to patients' requests for assisted death in countries where these actions are not legal. METHODS: A survey including statements concerning euthanasia and PAS and an open question about their actions when facing a request for assisted death was sent to all Finnish physicians. Quantitative data are presented as numbers and percentages. Statistical significance was tested by using the Pearson chi-square test, when appropriate. The qualitative analysis was performed by using an inductive content analysis approach, where categories emerge from the data. RESULTS: Altogether, 6889 physicians or medical students answered the survey, yielding a response rate of 26%. One-third of participants agreed or partly agreed that they could assist a patient in a suicide. The majority (69%) of the participants fully or partly agreed that euthanasia should only be accepted due to difficult physical symptoms, while 12% fully or partly agreed that life turning into a burden should be an acceptable reason for euthanasia. Of the participants, 16% had faced a request for euthanasia or PAS, and 3033 answers from 2565 respondents were achieved to the open questions concerning their actions regarding the request and ethical aspects of assisted death. In the qualitative analysis, six main categories, including 22 subcategories, were formed regarding the phenomenon of how physicians act when facing this request. The six main categories were as follows: providing an alternative to the request, enabling care and support, ignoring the request, giving a reasoned refusal, complying with the request, and seeing the request as a possibility. CONCLUSIONS: Finnish physicians' actions regarding the requests for assisted death, and attitudes toward euthanasia and PAS vary substantially. Open discussion, education, and recommendations concerning a request for assisted death and ethics around it are also highly needed in countries where euthanasia and PAS are not legal.

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.

Physicians' views on the role of relatives in euthanasia and physician-assisted suicide decision-making: a mixed-methods study among physicians in the Netherlands.

BACKGROUND: Relatives have no formal position in the practice of euthanasia and physician-assisted suicide (EAS) according to Dutch legislation. However, research shows that physicians often involve relatives in EAS decision-making. It remains unclear why physicians do (not) want to involve relatives. Therefore, we examined how many physicians in the Netherlands involve relatives in EAS decision-making and explored reasons for (not) involving relatives and what involvement entails. METHODS: In a mixed-methods study, 746 physicians (33% response rate) completed a questionnaire, and 20 were interviewed. The questionnaire included two statements on relatives' involvement in EAS decision-making. Descriptive statistics were used, and multivariable logistic regression analyses to explore characteristics associated with involving relatives. In subsequent interviews, we explored physicians' views on involving relatives in EAS decision-making. Interviews were thematically analysed. RESULTS: The majority of physicians want to know relatives' opinions about an EAS request (80%); a smaller group also takes these opinions into account in EAS decision-making (35%). Physicians who had ever received an explicit EAS request were more likely to want to know opinions and clinical specialists and elderly care physicians were more likely to take these opinions into account. In interviews, physicians mentioned several reasons for involving relatives: e.g. to give relatives space and help them in their acceptance, to tailor support, to be able to perform EAS in harmony, and to mediate in case of conflicting views. Furthermore, physicians explained that relatives' opinions can influence the decision-making process but cannot be a decisive factor. If relatives oppose the EAS request, physicians find the process more difficult and try to mediate between patients and relatives by investigating relatives' objections and providing appropriate information. Reasons for not taking relatives' opinions into account include not wanting to undermine patient autonomy and protecting relatives from a potential burdensome decision. CONCLUSIONS: Although physicians know that relatives have no formal role, involving relatives in EAS decision-making is common practice in the Netherlands. Physicians consider this important as relatives need to continue with their lives and may need bereavement support. Additionally, physicians want to perform EAS in harmony with everyone involved. However, relatives' opinions are not decisive.

Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium.

INTRODUCTION: Previous research has explored euthanasia's ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap exists in understanding the comprehensive value-based perspectives of other professionals involved in both somatic and psychiatric euthanasia. This paper aims to analyze the interplay among legal, medical, and ethical factors to clarify how foundational values shape the ethical discourse surrounding euthanasia in both somatic and psychiatric contexts. It seeks to explore these dynamics among all healthcare professionals and volunteers in Belgium. METHODS: Semi-structured interviews were conducted with 30 Dutch-speaking healthcare workers who had encountered patients requesting euthanasia for psychiatric conditions, in Belgium, from August 2019 to August 2020. Qualitative thematic analysis was applied to the interview transcripts. FINDINGS: Participants identified three pivotal values and virtues: religious values, professional values, and fundamental medical values encompassing autonomy, beneficence, and non-maleficence, linked to compassion, quality care, and justice. These values interwove across four tiers: the patient, the patient's inner circle, the medical realm, and society at large. Irrespective of their euthanasia stance, participants generally displayed a blend of ethical values across these tiers. Their euthanasia perspective was primarily shaped by value interpretation, significance allocation to key components, and tier weighting. Explicit mention of varying ethical values, potentially indicating distinct stances in favor of or against euthanasia, was infrequent. CONCLUSION: The study underscores ethical discourse's central role in navigating euthanasia's intricate landscape. Fostering inclusive dialogue, bridging diverse values, supports informed decision-making, nurturing justice, and empathy. Tailored end-of-life healthcare in psychiatry is essential, acknowledging all involved actors' needs. The study calls for interdisciplinary research to comprehensively grasp euthanasia's multifaceted dimensions, and guiding policy evolution. While contextualized in Belgium, the implications extend to the broader euthanasia discourse, suggesting avenues for further inquiry and cross-cultural exploration.

For, against, and beyond: healthcare professionals' positions on Medical Assistance in Dying in Spain.

BACKGROUND: In 2021, Spain became the first Southern European country to grant and provide the right to euthanasia and medically assisted suicide. According to the law, the State has the obligation to ensure its access through the health services, which means that healthcare professionals' participation is crucial. Nevertheless, its implementation has been uneven. Our research focuses on understanding possible ethical conflicts that shape different positions towards the practice of Medical Assistance in Dying, on identifying which core ideas may be underlying them, and on suggesting possible reasons for this disparity. The knowledge acquired contributes to understanding its complexity, shedding light into ambivalent profiles and creating strategies to increase their participation. METHODS: We conducted an exploratory qualitative research study by means of semi-structured interviews (1 h) with 25 physicians and nurses from primary care (12), hospital care (7), and palliative care (6), 17 women and 8 men, recruited from Madrid, Catalonia, and Andalusia between March and May 2023. Interviews were recorded, transcribed, and coded in Atlas.ti software by means of thematic and interpretative methods to develop a conceptual model. RESULTS: We identified four approaches to MAiD: Full Support (FS), Conditioned Support (CS), Conditioned Rejection (CR), and Full Rejection (FR). Full Support and Full Rejection fitted the traditional for and against positions on MAiD. Nevertheless, there was a gray area in between represented by conditioned profiles, whose participation cannot be predicted beforehand. The profiles were differentiated considering their different interpretations of four core ideas: end-of-life care, religion, professional duty/deontology, and patient autonomy. These ideas can intersect, which means that participants' positions are multicausal and complex. Divergences between profiles can be explained by different sources of moral authority used in their moral reasoning and their individualistic or relational approach to autonomy. CONCLUSIONS: There is ultimately no agreement but rather a coexistence of plural moral perspectives regarding MAiD among healthcare professionals. Comprehending which cases are especially difficult to evaluate or which aspects of the law are not easy to interpret will help in developing new strategies, clarifying the legal framework, or guiding moral reasoning and education with the aim of reducing unpredictable non-participations in MAID.

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.