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PubMed2003

Decision-making at the end-of-life and the incompetent patient: a comparative approach.

In contrast to the situation in the Netherlands and Belgium, the legislatures in both England & Wales and Germany have not recognised that active euthanasia may be lawful in any circumstance. Nevertheless, the courts in both jurisdictions have held that passive euthanasia, that is the withdrawal or withholding of life-prolonging treatment, is perfectly lawful; indeed it will often constitute good medical practice. This article adopts a comparative approach to assessing the manner in which decisions to withdraw or withhold life-prolonging treatment are made in relation to previously competent patients without a legally effective advance directive or a proxy decision-maker, considering the approaches adopted by the courts in England & Wales and Germany: the best interests and 'presumed will' approaches respectively. Due to the inherent drawbacks associated with each approach it is concluded that the best way forward would be for both jurisdictions to adopt a mixed approach, allowing the autonomy model to temper the best interests approach, recognising that the patient is an individual rather than simply an object of concern.

Decision Making↗

PubMed1998

Euthanasia and doctor-assisted suicide: responses by oncologists and non-oncologists.

PURPOSE: Public interest concerning euthanasia and doctor-assisted suicide is creating ethical dilemmas in the health care profession. We surveyed the views of oncologists and non-oncologists in Florida. METHODS: Physicians responded to an attitudinal questionnaire. The data collected were compared with standard statistical methods. RESULTS: Both oncologists and non-oncologists had similar opposition to euthanasia on philosophic or general grounds, with more opposition on general grounds expressed by oncologists. Both groups preferred better pain control and improved quality of life rather than euthanasia, but more oncologists than non-oncologists favored this alternative. Both groups admitted to participation in passive euthanasia, with little support for active euthanasia and doctor-assisted suicide. However, should the acts of euthanasia and doctor-assisted suicide become legalized, more non-oncologists than oncologists would agree to participate. CONCLUSION: In Florida, more opposition to aspects of the termination of life was expressed by oncologists than by non-oncologists.

Adult↗

PubMed1996

Ethical decision-making near the end of life.

For ethical decision-making near the end of life, autonomy is the moral North Star. At the same time, for some treatments, the burdens so clearly outweigh benefits that physicians may make a judgment not to offer the treatment. This is often clearer in surgery. A person with colon cancer and metastases may not insist on resection of the metastases. For some reason, some treatments have escaped these logical constraints. Attempted resuscitation of a dying patient is a good example. The circumstances in which a physician may make choices on behalf of a competent, terminally-ill patient without consent, and even without notification, are hotly debated, but data suggest that physicians do so frequently. Patients who lack capacity present even more difficult challenges. Advance directives, when available, can be extremely helpful, but even with them difficult problems can remain. If advance directives have not been established, family and close friends are an obvious source of guidance. Their legal role varies in different jurisdictions; in practice, they are crucial in bedside decision-making. Guardianship and alternatives to it remain a poor last resort. Euthanasia is a very difficult problem. We believe it is semantically misleading to lump under the term "passive euthanasia" those circumstances where potentially life-sustaining treatment is withheld or withdrawn. The tension between patient autonomy and medical common sense remains unresolved within the "futility" controversy. The authors believe it serves no purpose to discuss carefully with dying patients propositions that are nonsense. At the same time, physicians must not confuse decisions about quality of life with judgements about treatment effectiveness. We believe that what many, although not all, dying patients want are physicians with intelligent compassion who can take care of them through the dying process.

Advance Directives↗

PubMed1989

The right to die: a South African perspective.

The right to die is discussed here from a South African perspective. Even though there is still strong opposition to euthanasia in legal circles, organised religious groups and the public at large, there are academics and professionals who advocate passive euthanasia on moral grounds. If the right to die is seen (and accepted) as a mere continuation and extension of the right to a dignified life, there should be no valid opposition to it. Such acceptance will however go against judicial decisions that have been handed down in cases involving euthanasia.

Africa, Southern↗

PubMed1992

Italian neurologists and euthanasia: a poll.

We have tried to sound out Italian neurologists regarding their attitude to euthanasia, a very controversial issue today. We gave a short multiple-choice questionnaire to neurologists attending a national conference, asking their opinion on some issues related to euthanasia. 75 (25%) of the 300 doctors polled completed the questionnaire. Answers were often contradictory. A trend in favor of passive euthanasia among the respondents and a strong demand for guidelines are evident. Emotional rather than professional or rational factors seem to play a major role in the approach to this dilemma.

Attitude of Health Personnel↗

PubMed1990

[Death assistance and terminal care--at the hospital].

Euthanasia, i.e. active termination of life in a seriously ill patient, is not performed in Norway at present. Between active and so-called passive euthanasia there is a "grey zone", and it is discussed where the border should be drawn, how and by whom. The decision to treat or not is becoming increasingly difficult, due to technical advances in the development of life-supporting devices. There is increasing sympathy for the view that it is not the duty of the medical profession to prolong the life of patients under all circumstances. The present paper discusses such problems in relation to hospitalized patients in an acute life-threatening situation, and in patients with, known, chronic disabling, or malignant disease.

Euthanasia↗

PubMed1995

[Active euthanasia].

The growing interest in the subject of active euthanasia in connection with the debate regarding legalization of such practices in Denmark necessitates taking a definite standpoint. The difference in concept between active and passive euthanasia is stressed, and the Dutch guidelines are reviewed. The article discusses how far the patient's autonomy should go, as it regards the consideration of self-determination as being too narrow a criterion in itself. The discussion on the quality of life is included, and the consequences of the process of expulsion as a sociological concept are considered--the risk of a patient feeling guilty for being alive and therefore feeling compelled to request active euthanasia. The changed function of the physician is underlined, and it is discussed whether active euthansia will cause a breach of confidence between the physician and his patient. In connection with the debate the following tendencies in society are emphasized: lack of clarity, increasing medicalization and utilitarian priorities.

Denmark↗

PubMed1998

The dying thoracic patient.

Health care providers should understand that the practice of good medicine includes not only diagnosing and curing diseases, but also effectively communicating with patients and families and helping terminally ill patients die a peaceful and dignified death. Patients in America come from varied backgrounds, and it is important for physicians to consider cultural and religious issues. Physicians should combine their clinical judgment with objective outcome data to provide optimal care for patients. Informed consent should be obtained from patients after offering a detailed plan of care that would include appropriate interventions and the consequences of no intervention. The physician should then assist the patient in making a decision that would provide the best possible future for that individual. The four fundamental principles of biomedical ethics, namely beneficence, nonmaleficence, autonomy, and justice, should be considered when analyzing an ethical problem. Voluntary active euthanasia, which means performing a deliberate act (e.g., administering a lethal injection) to end a patient's life, should not be performed by a physician. Withholding and withdrawing basic and advanced life support constitutes passive euthanasia. Good communication with patients early in the clinical course whenever possible results in an ethically correct decision. A nonconfrontational, sympathetic, and compassionate approach to family members and legal surrogates facing the immediate death of their loved ones leads to the best possible outcome. It is the duty of the physician to assure the patient and the family that he or she will not abandon the patient. Effective communication is the key to solving almost all ethical dilemmas when caring for the dying thoracic patient.

Death↗

PubMed1995

Attitudes and behaviors on physician-assisted death: a study of Michigan oncologists.

PURPOSE: To ascertain the attitudes of oncologists toward physician-assisted death, ie, physician-assisted suicide and active euthanasia, as well as their experiences with these activities and their opinions toward their legalization. METHODS: A survey was mailed to all practicing 250 oncologists in the state of Michigan, with subsequent development of psychometric scales and their correlation with self-reported behaviors in physician-assisted death. RESULTS: Analysis revealed five distinct, meaningful factors regarding approval or disapproval of physician-assisted death. These factors reflected global attitudes toward physician-assisted death, passive euthanasia, philosophical prohibitions toward physician-assisted death, concerns of legal consequences with physician-assisted death, and attitudes that physician-assisted death could be avoided with better end-of-life care (alpha = .94, .74, .76, .87, and .84, respectively). High levels of therapy withdrawal were reported (81%), with significant reservations toward assisted suicide and active euthanasia, although reported participation in such actions was noteworthy (18% and 4%, respectively). The scales reflecting global and philosophical attitudes correlated with several attitudes and behaviors toward physician-assisted death (P < .001). Legislation that would allow physician-assisted death was favored by 20.8% of respondents. CONCLUSION: Although they have reservations about physician-assisted death, significant numbers of oncologists are willing to consider such actions should they become legal. Given the substantial number of physicians who report that they have already participated in physician-assisted death, these findings may help better understand the attitudes that motivate physician behaviors toward assisted death.

Attitude of Health Personnel↗

PubMedDate not supplied

[Survey of physicians' attitudes to terminal patients].

OBJECTIVE: To explore the opinion of physicians about euthanasia and the treatment of dying patients. DESIGN: A comparative survey. MATERIAL AND METHODS: We interviewed 38 family physicians (FP), 38 specialty physicians (SP) and 38 medical students (MS). The survey had 30 items, five of them about experience with terminal patients which were not used for the students. ANALYSIS: Descriptive statistics and chi 2 or Fisher test to compare proportions between groups. RESULTS: One hundred and two (89%) of the interviewed had a correct concept of euthanasia; 105 (92%) thought that life is holy and untouchable; 29 (25%) agreed there are persons more valuable than others, and four (4%) consider that some should die in certain situations. In relation to patients with brain death, 79 (69%) believed they should not receive futile treatment, but 42 (37%) said they should be attended until cardiac arrest occurred. All agreed with the need of the patients to receive comfort and peace, but only 49/76 (64%) of the physicians and 28 (74%) of the students were in favor of sending dying patients to their home. Nine FP (23%) and 14 SP (36%) stated that in many occasions they lacked elements to solve ethical dilemmas. Thirty six (32%) agreed with the use of passive euthanasia and 21 (18%) with active euthanasia; the latter was more frequent among students. Nine FP (24%) and 13 SP (34%) said they had exceeded therapy sometimes and 23 (61%) of the FP and 19 (50%) of the SP considered they had stopped treatment too early in some cases. We found no differences in regard to euthanasia between physicians and students (chi 2 = 0.32, p = 0.71) nor between the physicians with frequent vs occasional contact with terminal patients (Fisher = 0.13). CONCLUSIONS: A third of the physicians agreed with some form of euthanasia but this frequency is smaller than that in other countries.

Attitude of Health Personnel↗

PubMed1995

IASP task force on euthanasia and assisted suicide.

The first meeting of the IASP Task Force on Euthanasia and Assisted Suicide took place in Venice on June 7, 1995. Several interested observers were present. It was decided that at the public IASP meeting the following day each speaker should address, briefly, the current legal situation and the pressure for change, as well as give a personal statement. David Clark spoke for North America, Bob Goldney for Australia, Michael Kelleher for Britain and Ireland, Jerzy Wasserman for Scandinavia, and Hans Wedler for the German-speaking world. Their views are published in this article. Ad Kerkhof requested that the Dutch television film "Death on Request" be discussed. The committee was of the opinion that clear definitions were essential. In their view, these should take into account the differences between active and passive euthanasia, as well as between professionally assisted and lay-assisted suicide.

Australia↗

PubMed2001

[Intensive care - palliative care. Contradiction or supplement? Considerations on ethical issues and principles in the treatment of dying patients].

Over the last five decades the progress in intensive care has extended the limitations of controlling the process of dying and given doctors more influence in determining the time of death. More recently, palliative care has emerged as a new approach in response to the ethical dilemmas of modern medicine, which accepts that dying is a natural process that should not be hastened or delayed through medical interventions. While in Germany in 1999 more than 50 000 people have died in intensive care units, only a small number of 8000 patients have died in palliative care. In comparison to the highly-developed intensive care sector, palliative care is a much neglected area. The public debate following the legalisation of euthanasia in the Netherlands has highlighted concerns in Germany that intensive care has the potential of inappropriately prolonging life and raised expectations about the alternative therapies offered by palliative care. Doctors in intensive care and in palliative care face similar ethical dilemmas, though with a different weighting: the dilemma between professional judgement and patient autonomy, between traditional medical roles and patient self-determination and the dilemma of extending the span of life at the expense of quality of life. The approach of palliative care with its strong focus on alleviating the suffering of the terminally ill, has influenced the ethical debate of dying in intensive care. Although intensive care and palliative care have different aims and priorities, there are common problems of decision-making which could benefit from a shared orientation and interdisciplinary debate. Both the interpretation of a dying parent's will as well as withdrawing or withholding treatment in patients who are unable to decide for themselves should not merely be guided by the debate on active and passive euthanasia, but rather take into account the appropriateness or inappropriateness of medical actions in the specific situation.

Critical Care↗

PubMed1975

[Medical guidance of the cancer patient (author's transl)].

Cancer is a diseased state, but it is not incurable. Indications and methods of therapy have been standardized almost internationally. Early diagnosis leads to better rates of cure. Cancer presents as an individually characterized multiplicity of symptoms of the disease. Individualization is the real art of medicine. Truthful information, adjusted to the individual patient in each case, should be given at the right time. There should be no rush to make early statements of prognosis, especially statements of hopeless despair. No physician has the right to prolong the supravital and subhuman stage of dying. Absolute dominance of the physical time factor over the specifically human qualities and the patient's own individuality is not justified. The legal situation with regard to the gray area of passive euthanasia should be more clearly defined.

Euthanasia↗

PubMed1997

[Treatment of patients with thromboses of the basilar artery and locked-in syndrome. An ethical dilemma].

Decisions regarding the extent of treatment of severely ill patients can be an ethical dilemma when life-prolonging intensive care contradicts the goal of avoiding unnecessary suffering on the part of the patient. Here we present the results of a written survey of physicians on neurological intensive care units in Germany regarding the treatment of patients with basilar artery thrombosis and locked-in syndrome. 52% of the 93 physicians who replied advocated not treating severe infections with antibiotics, 38% were in favor of stopping intensive care. In contrast, 55% recommended intubating the patient in the presence of swallowing disturbances and imminent aspiration. 58% were in favor of discussing these problems in detail with the patient, and 87% advocated discussing them with relatives. Nearly all physicians (97%) recommended using adequate amounts of opiates and benzodiazepines. In very rare cases, 99% would agree to the use of passive euthanasia and 19% to active euthanasia. These findings illustrate the current disagreement on some of the important treatment decisions among physicians on neurological intensive care units. An open exchange of views on these questions could facilitate the appropriate consideration of ethical matters in the treatment of these patients.

Adult↗

PubMed2004

[Doctor and death].

Doctors are instilled with the need to avert and repress death. By virtue of their profession, death is considered the enemy, their mortal enemy. In modern-day hospitals in particular there is a tendency to reduce the mystery of death to a biological and technical algorithm. A critical revision of fundamental medical conduct is underway as a compensatory countercurrent to this age-old way of thinking and acting. This shift in attitudes involves a humane concept of the physician. His task is not limited to healing and reconstruction, but sometimes merely requires discriminatory restriction to palliation and accompaniment. Ever more physicians are becoming aware of the fact that they are equally responsible for the quality of dying. In coping with death, ethical imperatives are effectively juxtaposed against technical ones. Educational deficits relating to care of the terminally ill and dying have been recognized and are being rectified. This major ideational revision has led to concrete signs of turnaround which are blazing the trail toward more humane and dignified dying: palliation, adapted in accordance with modern science, is experiencing a renaissance. The essential features of a comprehensive palliative therapy are outlined. Assistance during dying (accompanying the dying, passive euthanasia) is contrasted with assistance to die (active euthanasia).

Attitude to Death↗

PubMed1998

[Attitude towards physician-assisted suicide among German doctors. A representative survey of the medical district association of Würzburg].

BACKGROUND AND OBJECTIVE: The widespread legalization of "physician assisted suicide" (PAS) in The Netherlands and comparable tendencies in other European countries have given rise to discussions of this topic in Germany. This questionnaire was undertaken because of the dearth of previous informative studies in Germany. SUBJECTS AND METHODS: Among all registered practicing doctors in the medical district of Würzburg (n = 1821) a randomly selected group of 150 (males and females) was asked to participate in a personal interview-enquiry about active and passive euthanasia. 93 (62%, 32% women, 61% men) agreed: 44.1% were doctors working in a hospital, 45.2% worked in their own practice, the others worked elsewhere or (3) were retired. All specialties and medical activities were represented. About 40% were general practitioners or worked in internal medicine. RESULTS: 81.7% of the group were against active PAS. All rejected it for non-moribund patients. CONCLUSIONS: The results of this study differ from similar enquiries in other countries in demonstrating a relatively strong rejection of active assistance in patient-suicide. Those German specialists who would most likely be confronted with this problem (e.g. neurologists, intensivists, anaesthetists, oncologists) tended towards a greater readiness to agree to physician-assisted suicide. A dialogue between doctors in different specialties is an urgent requirement and should be intensively pursued.

Attitude of Health Personnel↗

PubMed1989

U.S. and Australian nurses' attitudes and beliefs about the good death.

The purpose of this study was to ascertain the attitudes and beliefs of nurses in Australia and the United States regarding aspects of passive euthanasia, or the "good death." Two foci guided the study: (a) the possible discrepancies that these nurses might perceive between what they thought would be done in a given clinical situation and what they thought ought to be done, and (b) the possible differences and similarities between the American and the Australian nurses. Responding to the 8 vignettes, 30 American and 32 Australian nurses took part in the study. The lack of agreement between the Australian and American nurses on issues of euthanasia reflects differences in the health care system; the general social position of nursing as a profession; the relationship among health professionals, patients and families, which serves as the context for definition of ethical duties and patient rights; and the role of the law in health care decisions.

Adult↗

PubMedDate not supplied

A moral dilemma: killing and letting die.

Most health care professionals believe that there is a clear difference between killing and letting die, i.e. between active and passive euthanasia. Philosophers, however, have repeatedly attacked the moral validity of their argument. This article explores various related issues and theoretical approaches to the distinction between acts and omissions.

Beneficence↗