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PubMed1994

Euthanasia: the Dutch experience.

Although rules about euthanasia have been developed in the Netherlands, euthanasia has not been legalized. We review the historical aspects of euthanasia, its definition and why no distinction is now made between active and passive euthanasia in the Netherlands. The guidelines for euthanasia, in use in the Utrecht University Hospital, are presented and the result of some studies on euthanasia is discussed. Non-treatment decisions were taken in 17.5% of all deaths in 1990 but only 1.8% of all deaths were the result of euthanasia. Life-terminating acts without explicit and persistent request of the patients occurred in 0.8% of all deaths. The most common reasons for requests for euthanasia were loss of dignity in 57%, pain in 46%, distressing mode of dying in 46% and being dependent on others in 33%. Of all medical decisions concerning the end of life 79% related to patients older than 65 years. The guidelines for euthanasia developed in the Netherlands support both patient and physician in the request for euthanasia.

Aged↗
PubMedDate not supplied

Do German general practitioners support euthanasia? Results of a nation-wide questionnaire survey.

OBJECTIVE: To learn more about the attitudes of German general practitioners (GPs) concerning euthanasia and the frequency of its performance in Germany. METHODS: 500 GPs from all parts of Germany were randomly selected from telephone listings, and were sent a postal questionnaire with anonymous return envelopes. Participants were asked to make decisions based on hypothetical scenarios involving terminally ill patients and were questioned about their attitudes towards active euthanasia or physician assisted suicide (PAS). RESULTS: The questionnaire was returned by 48% of all 481 eligible GPs (mean age 51 years, 68% male). Although the option of performing euthanasia was rarely chosen in hypothetical scenarios, its performance was considered acceptable by 34% (active euthanasia) and 80% (PAS). Seventy-seven percent of respondents believed that a comparison between euthanasia today and the atrocities committed during the 3rd Reich was not appropriate. Sixty-two percent of respondents had received requests for active euthanasia and 73% for PAS. Thirteen percent and 38% of respondents seem to have performed euthanasia themselves in the past. CONCLUSIONS: The majority of German GPs reject active euthanasia and physician-assisted suicide (PAS). Nonetheless, requests for and performance of euthanasia do not seem to be a rare occurrence. Only a small proportion of respondents are willing to perform euthanasia at a patient's request under the current legislation which make these acts illegal in Germany. German history seems to play only a minor role in shaping respondents' attitudes towards active euthanasia or PAS.

Adult↗
PubMed1998

[Physician practice patterns and attitudes to euthanasia in Germany. A representative survey of physicians].

Growing life expectancy and increasing pharmaceutical and technical methods in medicine are leading to more and more discussions among the general population and among physicians as to whether methods to shorten the sufferings of mortally ill persons should be legalised further. In Australia 60% of physicians wish to be able to perform active euthanasia if this would be legal. In the Netherlands physicians do not commit an offence if they perform euthanasia on the basis of ethically consented rules. In the FRG the National Board of Physicians (Bundesärztekammer) still rejects any liberalisation concerning active euthanasia. However, little is known of the attitudes and behaviour of physicians concerning the questions of active and passive euthanasia. Sponsored by Gruner and Jahr publishers for a magazine "Stern" publication we conducted a representative study among physicians working in hospitals and their colleagues in free practices concerning this topic. Beginning with qualitative interviews with 50 physicians we tested the questionnaire developed and looked for the data production method best fitting for this difficult matter resulting in telephone interviews or a self-administered questionnaire. In the main study a representative sample of n = 282 physicians in free practices and n = 191 physicians in hospitals were interviewed. The response rates were 94% and 51% respectively. Analysis of non-responses did not indicate any bias. Half of the physicians think that a broader discussion on euthanasia is necessary, 34% disagree and 17% consider even a discussion already dangerous. 6% of the physicians in hospitals and 11% in free practices have already experienced methods of active euthanasia. Half of the physicians have seen patients who strongly wished euthanasia, a situation which happens once in every two years. The majority of physicians feel a deep understanding but only a minority of 4% comply with the wish. The vast majority of physicians advocate indirect euthanasia. However, they experience difficulties in defining the difference between active and passive euthanasia in a concrete situation. Summing up, our data indicate that a broader and open discussion on euthanasia seems necessary even if this discussion in Germany will be even more difficult than in other countries due to our recent past. The discussion will be reopened by a proposal on guidelines concerning euthanasia launched by the German National Board of Physician

Aged↗
PubMed2000

Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide.

BACKGROUND: The practices of euthanasia and physician-assisted suicide remain controversial. OBJECTIVE: To achieve better understanding of attitudes and practices regarding euthanasia and physician-assisted suicide in the context of end-of-life care. DESIGN: Cohort study. SETTING: United States. PARTICIPANTS: 3299 oncologists who are members of the American Society of Clinical Oncology. MEASUREMENTS: Responses to survey questions on attitudes toward euthanasia and physician-assisted suicide for a terminally ill patient with prostate cancer who has unremitting pain, requests for and performance of euthanasia and physician-assisted suicide, and sociodemographic characteristics. RESULTS: Of U.S. oncologists surveyed, 22.5% supported the use of physician-assisted suicide for a terminally ill patient with unremitting pain and 6.5% supported euthanasia. Oncologists who were reluctant to increase the dose of intravenous morphine for terminally ill patients in excruciating pain (odds ratio [OR], 0.61 [95% CI, 0.48 to 0.77]) and had sufficient time to talk to dying patients about end-of-life care issues (OR, 0.79 [CI, 0.71 to 0.87]) were less likely to support euthanasia or physician-assisted suicide. During their career, 3.7% of surveyed oncologists had performed euthanasia and 10.8% had performed physician-assisted suicide. Oncologists who were reluctant to increase the morphine dose for patients in excruciating pain (OR, 0.58 [CI, 0.43 to 0.79]) and those who believed that they had received adequate training in end-of-life care (OR, 0.86 [CI, 0.79 to 0.95]) were less likely to have performed euthanasia or physician-assisted suicide. Oncologists who reported not being able to obtain all the care that a dying patient needed were more likely to have performed euthanasia (P = 0.001). CONCLUSIONS: Requests for euthanasia and physician-assisted suicide are likely to decrease as training in end-of-life care improves and the ability of physicians to provide this care to their patients is enhanced.

Adult↗
PubMed2004

Drugs used for euthanasia in Flanders, Belgium.

PURPOSE: Our aim was to describe and assess the medicinal products and doses used for euthanasia in a series of cases, identified within an epidemiological death certificate study in Belgium, where euthanasia was until recently legally forbidden and where guidelines for euthanasia are not available. METHODS: In a random sample of the deaths in 1998 in Belgium, the physicians who signed the death certificates were identified and sent an anonymous mail questionnaire. The questionnaires of the deaths classified as euthanasia cases were reviewed by a multi-disciplinary panel. RESULTS: A total of 22 among 1925 questionnaires pertained to voluntary euthanasia. In 17 cases, detailed information on the euthanatics (medicinal substances used for euthanasia) used was provided. Opioids were used in 13 cases (in 7 as a single drug). Time between last dose and expiry ranged from 4 to 900 min. The panel judged that only in 4 cases effective euthanatics were used. CONCLUSIONS: In the end-of-life decision cases perceived by Belgian physicians as euthanasia, pharmacological practices were disparate, although dominated by the use of morphine, in the very late phase of dying, in doses which were unlikely to be lethal. Most physicians clandestinely engaging in euthanasia in Belgium seemed unaware of procedures for guaranteeing a quick, mild and certain death. Information on the pharmacological aspects of euthanasia should be included in the medical curriculum and continuing medical education, at least in countries with a legal framework permitting euthanasia under specified conditions.

Belgium↗
PubMed2000

An exploratory pilot study of nurse-midwives' attitudes toward active euthanasia and abortion.

Over the past three decades, active euthanasia and abortion have received increasing international attention. Since both these practices are relevant to the role of the nurse-midwife, it is important to know what influences their attitudes towards them. Therefore, the purpose of this study was: 1, to survey the attitudes of nurse-midwives' to active euthanasia and its legalization; 2, to determine the relationship between nurse-midwives' attitudes toward active euthanasia and its legalization, and attitudes toward abortion, self-reported religiosity and religious affiliation. The study setting was an international midwifery conference and the sample consisted of 139 nurse-midwives attending the conference. The majority of nurse-midwives displayed a positive attitude toward active euthanasia and its legalization. In addition, there was a positive relationship between their attitude to abortion and active euthanasia. Self-reported religiosity and religious affiliation were significantly related to attitudes toward active euthanasia and its legalization. An interesting positive relationship between country of practice and attitudes to euthanasia was also found. Nurse-midwives practicing in countries with more liberal euthanasia and assisted suicide legislation were more supportive of active euthanasia. With the increasing acceptance of active euthanasia's legalization, the results of this study pose some ethical questions that nurse-midwives internationally will have to consider.

Abortion, Induced↗
PubMed1997

Physician desire for euthanasia and assisted suicide: would physicians practice what they preach?

PURPOSE: Euthanasia is a pressing public issue. We sought to assess how frequently physicians could perceive of a desire for euthanasia themselves and whether they would be willing to provide patients the same interventions. METHODS: We interviewed 355 randomly selected oncologists from the United States and interviewed them about their attitudes and practices related to euthanasia and assisted suicide. RESULTS: Of the 355 oncologists, 48.1% could imagine a situation in which they might desire euthanasia or assisted suicide for themselves. Oncologists who were Catholic and more religious were significantly less likely to desire these interventions for themselves. Of those oncologists who could imagine a situation in which they might desire euthanasia or assisted suicide for themselves, 85.8% found euthanasia and/or assisted suicide acceptable for their patients. Of the oncologists who could not imagine a situation in which they might desire euthanasia or assisted suicide for themselves, 41.7% still found these interventions ethical for their patients. Only 6.8% of oncologists could imagine a situation in which they might desire euthanasia or assisted suicide for themselves but found these interventions unacceptable for their patients. CONCLUSION: Almost half of surveyed oncologists could imagine a situation in which they would desire euthanasia or assisted suicide. However, in many cases, this was for nonterminal illness which would be prohibited by proposed laws. When physicians desire euthanasia or assisted suicide for themselves, they are willing to provide these interventions for their patients; therefore, most physicians would practice what they preach. Indeed, when they deviate, oncologists overwhelmingly respect patient autonomy rather than impose their own views on patients.

Attitude to Death↗
PubMed1995

Nurses' definitions of and attitudes towards euthanasia.

A major impetus for this study was recent literature that assumed that nurses' definitions of euthanasia and consequent opinions on decision making are unproblematic. The purpose of this study was to identify nurses' definitions of and attitudes towards euthanasia. Ten semi-structured interviews were conducted with nurses working in a variety of clinical practice settings. The majority of nurses could distinguish between active and passive euthanasia, but it was only in terms of active euthanasia that the debate was seen as significant. It was considered that the term passive euthanasia, particularly in relation to withdrawal of treatment, has served to confuse the real debate centring around active euthanasia. Only two participants were in favour of active euthanasia, but emphasized the need for 'a community of shared responsibility' in decision making. The major finding of the study was the commitment of all participants to caring for and ensuring the comfort of the dying patient. The concepts of ordinary and extraordinary forms of treatment and heroic measures were seen as worthy of debate in the context of dying with dignity rather than of euthanasia. There was an associated aversion to inappropriate heroic measures, which were perceived as prolonging death and interfering with 'dying with dignity'. The development of a personal and moral/ethical stance (in relation to euthanasia) was shown to be an evolving process embedded in a caring philosophy and emphasizing the contextual nature of providing appropriate care.

Adult↗
PubMed2005

Prevalence and content of written ethics policies on euthanasia in Catholic healthcare institutions in Belgium (Flanders).

BACKGROUND: Euthanasia is performed worldwide, regardless of the existence of laws governing it. Belgium became the second country in the world to enact a law on euthanasia in 2002. Healthcare institutions bear responsibility for guaranteeing the quality of care for patients at the end of life, and for ensuring support for caregivers involved. Therefore, institutional ethics policies on end-of-life decision-making, especially on euthanasia, may be useful. METHODS: A cross-sectional mail survey of general directors of Catholic hospitals and nursing homes in Belgium was used to describe the prevalence and content of written ethics policies for competent terminally ill, incompetent terminally ill, and non-terminally ill patients. RESULTS: Of the 298 targeted institutions, 81% of hospitals and 62% of nursing homes returned complete questionnaires. Of these, 79% of hospitals and 30% of nursing homes had a written ethics policy on euthanasia. Of hospitals 83% and of nursing homes 85% permitted euthanasia for competent terminally ill patients only in exceptional cases in accordance with legal due care criteria and provisions outlined by the palliative filter procedure. Euthanasia for incompetent terminally ill patients was prohibited by 27% of the hospitals and by 60% of the nursing homes. For non-terminally ill patients, these figures were 43 and 64%, respectively. CONCLUSIONS: Catholic healthcare institutions in Belgium (Flanders) made great efforts to develop written ethics policies on euthanasia. Only a small group of institutions completely prohibited euthanasia. Most of the institutions considered euthanasia to be an option if all possible alternatives (e.g., palliative filter procedure, which contains more rigorous criteria than those in the Belgian Euthanasia Act), have been thoroughly investigated.

Belgium↗
PubMed2005

Attitudes of oncologists toward euthanasia in Turkey.

There have been intensive debates about euthanasia and attempts to change laws on euthanasia in all countries. What doctors and particularly oncologists think about euthanasia must be taken into consideration, as their voices are crucial in this dialogue. The aim of this study was to find out how Turkish doctors approach euthanasia in the context of cancer. A questionnaire was used to collect data from 85 oncologists out of a total 800 in active oncology practice. Of the oncologists surveyed, 43.8% did not object to euthanasia. Some 33.7% had been asked to perform euthanasia and 41.5% believed that euthanasia was performed secretly although it is against the law in Turkey. Forty-two doctors (50.6%) noted that they had withdrawn treatment in patients. Doctors who encounter terminally ill patients with cancer should update their knowledge about patients' rights and euthanasia. Doctors, who are often asked to perform euthanasia, especially in the cancer setting, can help to illuminate the debates about euthanasia.

Adult↗
PubMed2000

[Public opinion on active euthanasia. The results of a pilot project].

BACKGROUND AND OBJECTIVE: Despite eager public interest there have been few significant studies about the views of the German population on active euthanasia. It was our purpose to investigate, before undertaking a representative enquiry about this controversial and ethically sensitive topic, to what extent public opinion and the underlying norms, values and preferences can be adequately obtained by standardized data collection. COHORT AND METHODS: An interdisciplinary project group established a standardized written form of enquiry for measuring public opinion about active euthanasia. The test was performed on an anonymized convenience [corrected] sample of 110 persons living in North Germany. The questionnaires consisted of ten hypothetical cases, 11 potentially relevant viewpoints on likely decisions and eight frequently expressed arguments used in the debate for and against euthanasia. RESULTS: The reply rate to the questionnaire was 89% (n = 98; 37 men and 59 women, average age 39.5 [21-81] years). Agreement with active euthanasia in the various case examples ranged, according to context, from 85 to 93%. Active euthanasia was accepted by a clear majority, if preconditions of a voluntary decision by a mentally sound person and incurable, terminal disease (cancer) are cumulatively fulfilled. Otherwise it was rejected by most respondents. To a clear majority, active euthanasia implied both the chance that suffering would be shortened, but also the danger of misuse. Among the persons questioned those with professional experience of euthanasia were clearly more sceptical about active euthanasia than those without such experience. CONCLUSIONS: The standardized written questionnaire made it possible to obtain a differentiated picture of public opinion on active euthanasia. However, these data represent only a moment in the dynamic process of a norm being established within a society and must on no account be used as legitimizing active euthanasia by plebiscite.

Adult↗
PubMed1999

[Interdisciplinary discussion about euthanasia--viewpoint of the clinical physicians].

In western cities more than 80% of deaths occur in the hospital. Thus, we should be familiar with the professional care for dying patients. However, reports of euthanasia in the Netherlands and interviews of patients in other countries demonstrate that medical care for patients with end stage diseases frequently is insufficient. The need for palliative care, which encloses medical, psychological, social and spiritual aspects of the dying becomes apparent. The physical symptoms (e.g. pain) are only one aspect of the suffering of the terminally ill. Following the WHO guidelines for use of analgesic drugs pain control is achieved in the majority of patients. Palliative care may individually tailor the treatment and care to achieve symptom control. Legalization of euthanasia will diminish the interest in practicing palliative care and may also limit the enthusiasm in research in this field as seen in the Netherlands. Data analysis report significant increase of physician-assisted suicide and euthanasia in the Netherlands within five years time from 1990 to 1995 (total: 3.7% to 4.7%, euthanasia: 1.7% to 2.4%). In addition, each year about 1000 patients were not competent at the time euthanasia was performed (euthanasia without request)! Furthermore, a patients illness did not have to be in end stage when he required euthanasia. This information should rise concern about future developments! The public enthusiasm for legalization of euthanasia in Switzerland may reflect the fear of dying and the belief that physicians and other medical professionals are not equipped to adequately care for the dying. Indeed, professional competence of palliative medicine to treat the symptoms of terminally ill patients particularly with cancer has frequently been insufficient. The majority of Swiss dying with assisted suicide (Switzerland belongs to the few countries where assisted suicide is not illegal) in 1996 and more than 80% in the Netherlands dying by euthanasia had cancer. For the terminally ill euthanasia and assisted suicide may seem the only solution. Enhancing education in palliative medicine is a necessary first step to improve the care for the dying patients.

Attitude to Death↗
PubMed1994

Euthanasia. Historical, ethical, and empiric perspectives.

Debates about the ethics of euthanasia date from ancient Greece and Rome. In 1870, S. D. Williams, a nonphysician, proposed that anesthetics be used to intentionally end the lives of patients. Between 1870 and 1936, a debate about the ethics of euthanasia raged in the United States and Britain. These debates predate and invoke different arguments than do debates about euthanasia in Germany. Recognizing the increased interest in euthanasia, this article reviews the definitions related to euthanasia, the historical record of debates concerning euthanasia, the arguments for and against euthanasia, the situation in the Netherlands, and the empirical data regarding euthanasia in the United States.

Beneficence↗
PubMed1992

Pediatric euthanasia.

Pediatric euthanasia is currently practiced in the Netherlands on newborns, infants, children, and adolescents, although exact numbers are not known. Euthanasia in the Netherlands is generally assumed to be active and voluntary, but some cases of pediatric euthanasia would have to be characterized as nonvoluntary. Much of the motivation behind the euthanasia movement and the performance of pediatric euthanasia in the Netherlands is a genuine, compassionate desire to alleviate pain and suffering. In this study, we review the Dutch experience, with particular attention to the current practice of euthanasia on newborns, infants, children, and adolescents. We discuss pediatric euthanasia from an ethical point of view. We assert that more effective pain control, better symptom management, and psychosocial support of the dying and their families would alleviate the perception of suffering, and reduce the perceived need to resort to euthanasia.

Adolescent↗
PubMed1998

Euthanasia and related practices worldwide.

The present paper examines the occurrence of matters relating to the ending of life, including active euthanasia, which is, technically speaking, illegal worldwide. Interest in this most controversial area is drawn from many varied sources, from legal and medical practitioners to religious and moral ethicists. In some countries, public interest has been mobilized into organizations that attempt to influence legislation relating to euthanasia. Despite the obvious international importance of euthanasia, very little is known about the extent of its practice, whether passive or active, voluntary or involuntary. This examination is based on questionnaires completed by 49 national representatives of the International Association for Suicide Prevention (IASP), dealing with legal and religious aspects of euthanasia and physician-assisted suicide, as well as suicide. A dichotomy between the law and medical practices relating to the end of life was uncovered by the results of the survey. In 12 of the 49 countries active euthanasia is said to occur while a general acceptance of passive euthanasia was reported to be widespread. Clearly, definition is crucial in making the distinction between active and passive euthanasia; otherwise, the entire concept may become distorted, and legal acceptance may become more widespread with the effect of broadening the category of individuals to whom euthanasia becomes an available option. The "slippery slope" argument is briefly considered.

Ethics, Medical↗
PubMed1995

Euthanasia and the healthcare professional.

Euthanasia, often called mercy killing, is the act of inducing death often on terminally ill individuals for reasons assumed to be merciful. Euthanasia can be active or passive, and voluntary or involuntary. Voluntary euthanasia indicates the patient's full consent to terminate life, whereas involuntary euthanasia indicates the lack of patient's consent. Active euthanasia means the termination of life using an agent such as a drug, whereas passive euthanasia refers to the withholding a potentially life-prolonging treatment. Euthanatizing agents terminate life through various mechanisms, causing physical damage, direct or indirect tissue hypoxia, depression of the nervous system. Euthanasia is an issue filled with moral and ethical, as well as legal dilemmas that cannot be avoided. As members of the health care team, pharmacists may be asked to provide advice involving some form of euthanasia.

Euthanasia↗
PubMed1994

Willingness to perform euthanasia. A survey of physician attitudes.

BACKGROUND: In the United States, few studies have examined important variables in physician attitudes toward the practice of euthanasia, such as the patient's underlying disease, mental capacity, and age, and the physician's specialty and religion. We administered a case-based survey to analyze the impact of such specific variables on physician attitudes toward the practice. METHODS: A four-section survey solicited (1) physician responses to three hypothetical cases in which patients requested euthanasia; (2) physicians' general opinions about euthanasia and how its legalization might affect them personally and professionally; and (3) demographic information. Analysis focused on physicians' characteristics as they related to their responses to the various aspects of euthanasia elicited in the survey. Univariate and multivariate analyses, using logistic regression, were performed. RESULTS: Completed and analyzable surveys were returned by 740 physicians. We found that physicians felt more comfortable with euthanasia requests from nondecisional, nonterminal patients who had left advance directives than they did with requests from decisional patients suffering from grave illnesses or injuries, or from decisional patients who had early signs of a progressive but nonlethal neurologic disease. We also found that physicians' specialties and religions correlated with their responses to the hypothetical cases and with their generalized attitudes toward euthanasia. CONCLUSIONS: Given the disparity in responding physicians' attitudes toward euthanasia, along with the fact that values based on religious affiliation or profession may underlie many physicians' opposition to the practice, we conclude that if euthanasia is to be legalized, safeguards protective of patients and physicians must be incorporated.

Adult↗
PubMed2006

Physicians' opinions on palliative care and euthanasia in the Netherlands.

BACKGROUND: In recent decades significant developments in end-of-life care have taken place in The Netherlands. There has been more attention for palliative care and alongside the practice of euthanasia has been regulated. OBJECTIVE: The aim of this paper is to describe the opinions of physicians with regard to the relationship between palliative care and euthanasia, and determinants of these opinions. DESIGN: Cross-sectional. SETTING/SUBJECTS: Representative samples of physicians (n = 410), relatives of patients who died after euthanasia and physician-assisted suicide (EAS; n = 87), and members of the Euthanasia Review Committees (ERCs; n = 35). MEASUREMENTS: Structured interviews with physicians and relatives of patients, and a written questionnaire for the members of the ERCs. RESULTS: Approximately half of the physicians disagreed and one third agreed with statements describing the quality of palliative care in The Netherlands as suboptimal and describing the expertise of physicians with regard to palliative care as insufficient. Almost two thirds of the physicians disagreed with the suggestion that adequate treatment of pain and terminal care make euthanasia redundant. Having a religious belief, being a nursing home physician or a clinical specialist, never having performed euthanasia, and not wanting to perform euthanasia were related to the belief that adequate treatment of pain and terminal care could make euthanasia redundant. CONCLUSION: The study results indicate that most physicians in The Netherlands are not convinced that palliative care can always alleviate all suffering at the end of life and believe that euthanasia could be appropriate in some cases.

Adult↗