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PubMed1982

Debate: euthanasia--a physician's viewpoint.

Discussion about euthanasia is often confused because of a failure to distinguish between deliberate death acceleration and letting nature take its course. There is a need to reiterate the traditional principles upon which the care of the dying should be based, including the need for the doctor to practise medicine in the knowledge that eventually all his patients will die. It follows that a doctor does not have a duty to preserve life at all costs. The care of the patient with far-advanced cancer has improved considerably in many areas as a result of the establishment of hospices and domiciliary support teams. Treating the patient as a person is the key to a successful doctor-patient relationship. An analytical approach is necessary to control pain and other symptoms. Care of the relatives is also fundamental. Voluntary euthanasia and 'assisted suicide' represent an extreme solution to a situation which demands a far more comprehensive and compassionate approach. The need is not for a change in the law but for a change of emphasis in medical education.

Ethics, Medical↗
PubMed2002

Open regulation and practice in assisted dying.

The Netherlands, Oregon and Switzerland are the only areas in the world where assistance in dying has legally been practised in recent years. This article provides a detailed comparison of the history of the origins, legislation, monitoring systems and the extent of assistance in dying in these three places. It shows that the actual practice in Switzerland which, unlike Oregon, also allows assistance in suicide by means of infusions or gastric tubes, can today be technically quite similar to the permitted practice of active euthanasia on request in the Netherlands. Considering the preconditions restricting these practices, Swiss regulations are the most open, in that the law requires neither a medical second opinion (as in both the Netherlands and Oregon) nor the existence of a terminal illness (as in Oregon) as prerequisite to assistance in dying. In 2001, the proportion of assisted deaths (as reported to the authorities) in all deaths was almost ten times higher in the Netherlands (1.5% of all deaths) then in Oregon (<0.1% of all deaths) or Switzerland (0.2% of all deaths). The analysis of the different normative concepts underlying legislation reveals that in the Netherlands the basis for non-prosecution lies in the conflict of the physician's duties to respect life versus relief of suffering, while in the USA and in Switzerland the right-to-die concept plays a major role. These two concepts allow appreciation of distinctions between the roles of the physician in end-of-life practices and between assisted suicide and voluntary active euthanasia.

Euthanasia↗
PubMed2003

Non-voluntary and involuntary euthanasia in The Netherlands: Dutch perspectives.

During the summer of 1999, twenty-eight interviews with some of the leading authorities on euthanasia policy were conducted in the Netherlands. They were asked about cases of non-voluntary (when patients are incompetent) and involuntary euthanasia (when patients are competent and made no request to die). This study reports the main findings, showing that most respondents are quite complacent with regard to breaches of the guideline that require the patient's consent as a prerequisite to performance of euthanasia.

Aged↗
PubMed1998

The moral case for the legalisation of voluntary euthanasia.

If a person is suffering from illness or disability and wishes to end their life the law ought to facilitate rather than frustrate that choice argues Graham Oddie in this article. He points out the inconsistencies in current medical practice, and the gross disparity between the practice and the letter of the law. In dismissing many of the commonly raised objections to calls for reform of the law permitting euthanasia he makes a strong case for consistency in our approach to the right to die and patient autonomy.

Australia↗
PubMed2000

Patients' knowledge of options at the end of life: ignorance in the face of death.

CONTEXT: Effectiveness of legislation promoting advance directives and legalizing physician-assisted suicide depends on patients' understanding their legal options about end-of-life care. However, outpatients' understanding of their legal options at the end of life has not been studied. OBJECTIVES: To estimate the percentage of outpatients who are informed about 4 areas relevant to end-of-life care: refusal and withdrawal of lifesaving treatments, physician-assisted suicide, active euthanasia, and double effect; and to determine whether authoring advance directives, experiencing illness, acting as a proxy for health care decisions, and caring for an ill loved one are associated with better knowledge in end-of-life care. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: One thousand consecutive English-speaking, adult patients attending 1 university-based internal medicine clinic and 3 community-based, university-affiliated, mixed internal medicine and family practice clinics in Oregon during May and June 1999. MAIN OUTCOME MEASURES: Percentage of correct responses in the 4 topic areas and total knowledge score, adjusted for demographic (eg, age, race, educational level, income level, marital status) and experiential (eg, health, proxy decision making, advance directives, and death of a loved one) factors. RESULTS: Of the 1000 patients invited to participate, 728 (73%) consented and completed the questionnaire and were included in the analysis. A total of 69% of respondents answered correctly regarding refusal of treatment, 46% for withdrawal of treatment, 23% for assisted suicide, 32% for active euthanasia, and 41% for double effect. Sixty-two percent of respondents did not distinguish between assisted suicide and euthanasia. After adjustment for other covariates, better knowledge was significantly associated with white race (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3-4.2), having at least a college degree (OR, 3.0; 95% CI, 1.4-6.7), and having been a proxy for health care decisions (OR, 1.8; 95% CI, 1.2-2.6). Personal experience with illness (OR, 1.0; 95% CI, 0.6-1.5), death or illness of a loved one (OR, 1.6; 95% CI, 1.0-2.7), and authoring an advance directive (OR,1.3; 95% CI, 0.9-2.0) were not associated with better knowledge. CONCLUSIONS: A significant proportion of outpatients at university-affiliated clinics in Oregon appear to misunderstand options in end-of-life care. Our results suggest that greater public knowledge about end-of-life care is needed, and advance care planning must be preceded by education about options in end-of-life care. JAMA. 2000;284:2483-2488.

Adult↗
PubMed2000

Seven legal barriers to end-of-life care: myths, realities, and grains of truth.

OBJECTIVE: The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel was convened in 1997 to identify clinical, ethical, and policy problems in end-of-life care, to analyze critically the available evidence and guidelines, and to offer consensus recommendations on how to improve care of the dying. Topic selection and content presentation were carefully debated to maximize the project's focus on providing practical clinical and other guidance to clinicians who are not specialists in palliative care. This statement examines current legal myths, realities, and grains of truth in end-of-life care. PARTICIPANTS: The Consensus Panel comprises 13 medical and bioethics experts, clinicians, and educators in care at the end of life selected by the Ethics and Human Rights Committee, College leadership, and the Center for Ethics and Professionalism at the ACP-ASIM. EVIDENCE: A literature review including a MEDLINE search of articles from 1970-1998 and review of end-of-life care literature and organizational bibliographies was conducted. Unpublished sources were also identified by participants, as was anecdotal clinical experience. CONSENSUS PROCESS: The draft statement was debated by panel members over a series of 3 to 4 meetings. For this statement, the initial draft and subsequent revised drafts were discussed in 1998-1999. The statement then underwent external peer review and revision before panel approval and the journal peer review process. CONCLUSIONS: Legal myths about end-of-life care can undermine good care and ethical medical practice. In addition, at times ethics, clinical judgment, and the law conflict. Patients (or families) and physicians can find themselves considering clinical actions that are ethically appropriate, but raise legal concerns. The 7 major legal myths regarding end-of-life care are: (1) forgoing life-sustaining treatment for patients without decision-making capacity requires evidence that this was the patient's actual wish; (2) withholding or withdrawing of artificial fluids and nutrition from terminally ill or permanently unconscious patients is illegal; (3) risk management personnel must be consulted before life-sustaining medical treatment may be terminated; (4) advance directives must comply with specific forms, are not transferable between states, and govern all future treatment decisions; oral advance directives are unenforceable; (5) if a physician prescribes or administers high doses of medication to relieve pain or other discomfort in a terminally ill patient, resulting in death, he/she will be criminally prosecuted; (6) when a terminally ill patient's suffering is overwhelming despite palliative care, and he/she requests a hastened death, there are no legally permissible options to ease suffering; and (7) the 1997 Supreme Court decisions outlawed physician-assisted suicide. Many legal barriers to end-of-life care are more mythical than real, but sometimes there is a grain of truth. Physicians must know the law of the state in which they practice. JAMA. 2000;284:2495-2501.

Advance Directives↗
PubMed1993

Euthanasia.

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Aged↗