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Attitudes Among Patients With Advanced Cancer Toward Euthanasia and Living Wills
... The comparison related to the knowledge questions showed that the differences between groups were related to the meaning of the terms 'active euthanasia', 'palliative sedation', and 'biological testament'. Some authors described that levels of understanding around the legal options of EoL care is a current issue, due to the fragmented information currently available by the media and the diverse legislation among countries (Mercadante, Costanzi, Marchetti, & Casuccio, 2016). The debate around themes such as euthanasia is very active (Mercadante et al., 2016), but this study's results showed that the general public is little informed about the peculiarities related to specific EoL topics such as understanding the meaning of 'active euthanasia', 'palliative sedation', and 'biological testament'. ...
... Some authors described that levels of understanding around the legal options of EoL care is a current issue, due to the fragmented information currently available by the media and the diverse legislation among countries (Mercadante, Costanzi, Marchetti, & Casuccio, 2016). The debate around themes such as euthanasia is very active (Mercadante et al., 2016), but this study's results showed that the general public is little informed about the peculiarities related to specific EoL topics such as understanding the meaning of 'active euthanasia', 'palliative sedation', and 'biological testament'. This gap in public knowledge could undermine many debates, affecting the real awareness related to the options in EoL care, and it could generate stereotypes about the same EoL choices and meanings. ...
Background:
The current debate regarding decision-making at the End-of-Life (EoL) is increasing remarkably and has spread all over the world. However, literature has paid little attention to describe choice's differences in EoL care between healthcare professionals and general public.
Objectives:
The aim of this study was to explore the difference between choices in EoL care made by healthcare professionals and those of the general public within the Italian context.
Setting and participants:
In 2017, an Italian widespread survey was conducted using a snowball sampling. A total of 2038 participants completed the survey, 55.64% of which were the general public.
Results:
The main differences related to specific EoL choices made by healthcare professionals and the general public. In particular, healthcare professionals were more likely to avoid cardiopulmonary resuscitation and mechanical forms of breathing in terminal-stage conditions, and they were also more likely to be favorable towards the use of opioids to avoid suffering. Overall, healthcare professionals were also more likely to make a choice rather than express a 'not sure' answer.
Conclusion:
The higher percentage of participants in the general public group that chose 'not sure' highlighted the importance of addressing and enhancing people's self-awareness. More cross-national investigation should help to frame the understanding of the choice's differences in EoL care between healthcare professionals and general public.
... Cuando los profesionales de la salud desconocen a fondo el concepto de la eutanasia y las posibilidades de emitir voluntades anticipadas, no es posible que en la información a sus pacientes se incluya todo lo necesario para que éstos puedan tomar una decisión acorde con sus intereses. Los estudios apuntan a la necesidad de más investigación sobre el tema, ya que una mayoría tienen muestras pequeñas que no permiten generalizar los resultados (Mercadante, 2016). ...
... Cuando los profesionales de la salud desconocen a fondo el concepto de la eutanasia y las posibilidades de emitir voluntades anticipadas, no es posible que en la información a sus pacientes se incluya todo lo necesario para que éstos puedan tomar una decisión acorde con sus intereses. Los estudios apuntan a la necesidad de más investigación sobre el tema, ya que una mayoría tienen muestras pequeñas que no permiten generalizar los resultados (Mercadante, 2016). ...
Cancer is a multifactorial and multidimensional process; its approach
necessarily requires interdisciplinary work to influence all the edges
involved. From the psychological dimension, psycho-oncology promises a constantly evolving field that offers effective strategies. The growth and interdisciplinary link of this area rests on the biopsychosocial model and on the psychoneuroimmunological mechanisms that provide theoretical support to psychosocial interventions and give prominence not only to the cancer patient, but also to family members and health personnel. Currently, there are evidence-based interventions such as those that can be seen in table 1 that, through the adaptation of their techniques, allow them to influence the main objectives and challenges such as understanding the disease, increasing quality of life, adherence to treatment, stress management, the generation of social support networks, among others in the cancer process. The relevance of timely care and comprehensive intervention is evident, which, starting from a biopsychosocial perspective, provides an interdisciplinary approach to cancer patients, their families and health professionals.
This chapter aims to describe the background of psycho-oncology
as well as its contributions to the approach to cancer. Likewise, some psychosocial interventions in cancer will be described in different agents involved: cancer patient, family and health professionals.
... In several studies around the world, patients reported a strong interest for advance directives (AD) or ACP [21][22][23][24][25]. Nonetheless, the percentage of people who effectively have AD remains very low in the general population [26,27]. ...
Patients living with cancer often experience serious adverse events due to their condition or its treatments. Those events may lead to a critical care unit admission or even result in death. One of the most important but challenging parts of care is to build a care plan according to the patient’s wishes, meeting their goals and values. Advance directives (ADs) allow everyone to give their preferences in advance regarding life sustaining treatments, continuation, and withdrawal or withholding of treatments in case one is not able to speak their mind anymore. While the absence of ADs is associated with a greater probability of receiving unwanted intensive care around the end of their life, their existence correlates with the respect of the patient’s desires and their greater satisfaction. Although progress has been made to promote ADs’ completion, they are still scarcely used among cancer patients in many countries. Several limitations to their acceptance and use can be detected. Efforts should be made to provide tailored solutions for the identified hindrances. This narrative review aims to depict the situation of ADs in the oncology context, and to highlight the future areas of improvement.
... In several studies around the world, patients reported a strong interest for AD or ACP [20][21][22][23][24]. Nonetheless, the percentage of people who effectively have AD remains very low in the general population [25,26]. ...
Patients living with cancer often experience serious adverse events due to their condition or its treatments. Those events may lead to a critical care unit admission or even result in death. One of the most important but challenging part of care is to build a caring plan according to the patient’s wishes, meeting his goals and values. Advance directives (ADs) allow everyone to give their preferences in advance regarding life sustaining treatments, continuation, and withdrawal or withholding of treatments in case one is not able to speak his mind anymore. While the absence of ADs is associated with a greater probability of receiving unwanted intensive care around the end of his life, their existence correlates with the respect of the patient’s desires and his greater satisfaction. Although progress has been made to promote ADs’ completion, they are still scarcely used among cancer patients in many countries. Several limitations to their acceptation and use can be detected. Efforts should be made to provide tailored solutions for the identified hindrances. This narrative review aims to depict the situation of ADs in the oncology context, and to highlight the future areas of improvement.
... In order to guarantee autonomy to dying persons, domestic scholars propose the use of living wills, also known as "advance directives." A living will is a written document that allows a patient to give explicit instructions about medical treatments to be administered when he or she is terminally ill and unable to communicate [22]. It is believed that living wills help patients exercise autonomy at the end of their lives and die with dignity. ...
Purpose of review:
This review was undertaken to analyze the main reasons behind the limited development of hospice care in China, and to put forward some suggestions.
Recent findings:
Although the Chinese government has increased its support for hospice care in recent years, however, owing to the lack of education around hospice care and the heavy influence of the traditional Chinese Confucian concept of "filial piety," many individuals resist hospice care. Moreover, due to impaired patient rights, inadequate composition of hospice care teams, unbalanced geographical distribution, and limited service range, the development of hospice care in China is hindered. Hospice care education and continued training should be popularized and the government should strengthen the legal structure of the medical system to protect the rights of patients, families, and medical staff to promoting social support for hospice care. Through graded diagnosis and referral systems in medical institutions to integrate medical resources and expand the range of hospice care services.
... Of concern, it has been recently reported that there is a lack of knowledge among patients about the meaning of end-of-life issues. 2 Physician-assisted suicide and euthanasia have been increasingly debated in the public arena, and in some European countries, legislation exists to regulate these end-of-life issues. 3 Euthanasia and assisted suicide have been legal in The Netherlands and Belgium since 2002. ...
... To further understand this area, factors associated with opinions regarding euthanasia seems to be a key issue. Other authors have instigated attitudes of patients with advanced cancer towards euthanasia and/or living wills but did not report any determinants factors associated with favorable or unfavorable opinion [14][15][16]. To the best of our knowledge, our study is the first identifying determinants associated with favorable or unfavorable opinion about euthanasia in cancer patients receiving palliative care. ...
Abstract Background Opinion about euthanasia has been explored among the general population and recently in patients receiving palliative care. 96% of the French population declared themselves in favor of euthanasia while less of 50% of palliative care patients are. The aim of the present study was to explore and identify potential determinant factors associated with favorable or unfavorable opinion about euthanasia in a French population of cancer patients receiving palliative care. Methods We performed a cross-sectional study among patients in two palliative care units. Eligible patients were identified by the medical staff. Face-to-face interviews were performed by two investigators. Two groups were defined as favorable or unfavorable about euthanasia according to the answer on the specific question about patient opinion on euthanasia. A multivariate analysis including age, belief in God, chemotherapy and gender was built. Results Seventy-eight patients were interviewed. Median age was 60.5 years (range: 31–87.2). In univariate analysis, patients with a favorable opinion were most often under 60 years old (62 versus 38% unfavorable; p = 0.035), in couple (64 versus 35%; p = 0.032), didn’t believe in God (72 versus 28% were non-believers; p
Objectives
The French government voted a new law in February 2016 called the Claeys-Leonetti Law, which established the right to deep and continuous sedation, confirmed the ban on euthanasia and ruled out physician-assisted suicide. The aim of this work was to gather the opinion of patients on continuous sedation and the legalisation of medical assistance in dying and to explore determinants associated with favourable and unfavourable opinions.
Methods
This was a French national prospective multicentre study between 2016 and 2020.
Results
331 patients with incurable cancer suffering from locally advanced or metastatic cancer in 14 palliative care units were interviewed. 48.6% of participants expressed a favourable opinion about physician-assisted suicide and 27.2% an unfavourable opinion about its legalisation. Regarding euthanasia, 52% of patients were in favour of its legalisation. In univariate analysis, the only factor determining opinion was belief in God.
Conclusions
While most healthy French people are in favour of legalising euthanasia, only half of palliative care patients expressed this opinion. Medical palliative care specialists were largely opposed to euthanasia. The only determining factor identified was a cultural factor that was independent of the other studied variables. This common factor was found in other studies conducted on cohorts from other countries. This study contributes to the knowledge and thinking about the impact of patients’ personal beliefs and values regarding their opinions about euthanasia and assisted suicide.
Trial registration number
NCT03664856 .
Alla base di questa ricerca vi è l’analisi delle varie modalità con cui il testamento biologico e le norme che lo garantiscono hanno preso forma negli scenari italiano, europeo e statunitense. In particolare, viene posta l’attenzione sulle percezioni dei cittadini e, più nello specifico, di pazienti e operatori sanitari, in merito al tema del fine-vita e del biotestamento. È venuto quindi a delinearsi un quadro estremamente variegato dai numerosi spunti di analisi.
L’obiettivo del mio lavoro è stato quindi quello di mettere in luce quelli che sono i fattori e le differenze culturali che influiscono nei processi inerenti al biotestamento, delineando quelle che possono essere le modalità per incentivare il dialogo sulla pianificazione e sulle disposizioni anticipate di trattamento.
Ho concentrato maggiore enfasi sulla questione italiana e la ragione di questa scelta è fondamentalmente duplice: da una parte il tema mi riguarda in prima persona in quanto cittadino italiano, dall’altra per la necessità di promuovere il dialogo su alcune tematiche tutt’oggi in fase di delineazione nel nostro Paese.
Context
Healthcare professionals (HCPs) are crucial to physician-assisted death (PAD) provision.Objectives: To quantitatively assess the favorability of justifications for or against PAD legalization among HCPs, the effect of the terms “suicide” and “euthanasia” on their views, and their support for three forms of PAD.
Methods
Our questionnaire presented three cases: physician-assisted suicide, euthanasia for a competent patient, and euthanasia for an incompetent patient with an advance directive for euthanasia. Respondents judged whether each case was ethical and should be legal, and selected their justifications from commonly cited reasons. The sample included physician clinicians, researchers, non-physician clinicians, and other non-clinical staff at a major academic medical center.
Results
Of 221 HCPs, the majority thought each case was ethical and should be legal. In order of declining favorability, justifications supporting PAD legalization were relief of suffering, right to die, mercy, acceptance of death, non-abandonment, and saving money for the healthcare system; opposing justifications were the slippery slope argument, unnecessary due to palliative care, killing patients is wrong, religious views, and suicide is wrong. Use of suicide and euthanasia terminology did not affect responses. Participants preferred physician-assisted suicide to euthanasia for a competent patient (p<0.0001) and euthanasia for an incompetent patient to euthanasia for a competent patient (p<0.005).
Conclusions
HCPs endorsed patient-centered justifications over other reasons, including role-specific duties. Suicide and euthanasia language did not bias HCPs against PAD, challenging claims that such value-laden terms hinder dialogue. More research is required to understand the significance of competency in shaping attitudes toward PAD.
Background:
In recognition of the ongoing discussion on euthanasia and physician-assisted suicide, the Board of Directors of the European Association for Palliative Care commissioned this white paper from the palliative care perspective.
Aim:
This white paper aims to provide an ethical framework for palliative care professionals on euthanasia and physician-assisted suicide. It also aims to provide an overview on the available evidence as well as a discourse of ethical principles related to these issues.
Design:
Starting from a 2003 European Association for Palliative Care position paper, 21 statements were drafted and submitted to a five-round Delphi process PARTICIPANTS: A panel with 17 experts commented on the paper in round 1. Board members of national palliative care or hospice associations that are collective members of European Association for Palliative Care were invited to an online survey in rounds 2 and 3. The expert panel and the European Association for Palliative Care board members participated in rounds 4 and 5. This final version was adopted as an official position paper of the European Association for Palliative Care in April 2015.
Results:
Main topics of the white paper are concepts and definitions of palliative care, its values and philosophy, euthanasia and physician-assisted suicide, key issues on the patient and the organizational level. The consensus process confirmed the 2003 European Association for Palliative Care white paper and its position on the relationship between palliative care and euthanasia and physician-assisted suicide.
Conclusion:
The European Association for Palliative Care feels that it is important to contribute to informed public debates on these issues. Complete consensus seems to be unachievable due to incompatible normative frameworks that clash.
Background:
The practice of euthanasia and physician-assisted suicide (PAS) in the Netherlands has been regulated since 2002 by the Euthanasia Act. In the ongoing debate about the interpretation of this Act, comparative information about the opinions of the different stakeholders is needed.
Aim:
To evaluate the opinions of Dutch physicians, nurses and the general public on the legal requirements for euthanasia and PAS.
Design:
A cross-sectional survey among Dutch physicians and nurses in primary and secondary care and members of the Dutch general public, followed by qualitative interviews among selected respondents. The participants were: 793 physicians, 1243 nurses and 1960 members of the general public who completed the questionnaire; 83 were interviewed.
Results:
Most respondents agreed with the requirement of a patient request (64-88%) and the absence of a requirement concerning life expectancy (48-71%). PAS was thought acceptable by 24-39% of respondents for patients requesting it because of mental suffering due to loss of control, chronic depression or early dementia. In the case of severe dementia, one third of physicians, 58% of nurses and 77% of the general public agreed with performing euthanasia based on an advance directive. Interviewees illustrated these findings and supported the Act.
Conclusions:
Health care professionals and the general public mostly support the legal requirements for euthanasia and PAS. The law permits euthanasia or PAS for mental suffering but this possibility is not widely endorsed. The general public is more liberal towards euthanasia for advanced dementia than health care professionals. We conclude that there is ample support for the law after eight years of legal euthanasia.
Recent discussions about health care reform have raised questions regarding the value of advance directives.
We used data from survey proxies in the Health and Retirement Study involving adults 60 years of age or older who had died between 2000 and 2006 to determine the prevalence of the need for decision making and lost decision-making capacity and to test the association between preferences documented in advance directives and outcomes of surrogate decision making.
Of 3746 subjects, 42.5% required decision making, of whom 70.3% lacked decision-making capacity and 67.6% of those subjects, in turn, had advance directives. Subjects who had living wills were more likely to want limited care (92.7%) or comfort care (96.2%) than all care possible (1.9%); 83.2% of subjects who requested limited care and 97.1% of subjects who requested comfort care received care consistent with their preferences. Among the 10 subjects who requested all care possible, only 5 received it; however, subjects who requested all care possible were far more likely to receive aggressive care as compared with those who did not request it (adjusted odds ratio, 22.62; 95% confidence interval [CI], 4.45 to 115.00). Subjects with living wills were less likely to receive all care possible (adjusted odds ratio, 0.33; 95% CI, 0.19 to 0.56) than were subjects without living wills. Subjects who had assigned a durable power of attorney for health care were less likely to die in a hospital (adjusted odds ratio, 0.72; 95% CI, 0.55 to 0.93) or receive all care possible (adjusted odds ratio, 0.54; 95% CI, 0.34 to 0.86) than were subjects who had not assigned a durable power of attorney for health care.
Between 2000 and 2006, many elderly Americans needed decision making near the end of life at a time when most lacked the capacity to make decisions. Patients who had prepared advance directives received care that was strongly associated with their preferences. These findings support the continued use of advance directives.
Euthanasia and physician-assisted suicide (PAS) are highly controversial issues. While there are studies of seriously ill patients' interest in euthanasia and PAS, there are no data on the attitudes and desires of terminally ill patients regarding these issues.
To determine the attitudes of terminally ill patients toward euthanasia and PAS, whether they seriously were considering euthanasia and PAS for themselves, the stability of their desires, factors associated with their desires, and the proportion of patients who die from these interventions.
Prospective cohort of terminally ill patients and their primary caregivers surveyed twice between March 1996 and July 1997.
Outpatient settings in 5 randomly selected metropolitan statistical areas and 1 rural county.
A total of 988 patients identified by their physicians to be terminally ill with any disease except for human immunodeficiency virus infection (response rate, 87. 4%) and 893 patient-designated primary caregivers (response rate, 97. 6%).
Support for euthanasia or PAS in standard scenarios; patient-expressed considerations and discussions of their desire for euthanasia or PAS; hoarding of drugs for suicide; patient death by euthanasia or PAS; and patient-reported sociodemographic factors and symptoms related to these outcomes.
Of the 988 terminally ill patients, a total of 60.2% supported euthanasia or PAS in a hypothetical situation, but only 10. 6% reported seriously considering euthanasia or PAS for themselves. Factors associated with being less likely to consider euthanasia or PAS were feeling appreciated (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52-0.82), being aged 65 years or older (OR, 0.52; 95% CI, 0.34-0.82), and being African American (OR, 0.39; 95% CI, 0. 18-0.84). Factors associated with being more likely to consider euthanasia or PAS were depressive symptoms (OR, 1.25; 95% CI, 1.05-1. 49), substantial caregiving needs (OR, 1.09; 95% CI, 1.01-1.17), and pain (OR, 1.26; 95% CI, 1.02-1.56). At the follow-up interview, half of the terminally ill patients who had considered euthanasia or PAS for themselves changed their minds, while an almost equal number began considering these interventions. Patients with depressive symptoms (OR, 5.29; 95% CI, 1.21-23.2) and dyspnea (OR, 1.68; 95% CI, 1.26-2.22) were more likely to change their minds to consider euthanasia or PAS. According to the caregivers of the 256 decedents, 14 patients (5.6%) had discussed asking the physician for euthanasia or PAS and 6 (2.5%) had hoarded drugs. Ultimately, of the 256 decedents, 1 (0.4%) died by euthanasia or PAS, 1 unsuccessfully attempted suicide, and 1 repeatedly requested for her life to be ended but the family and physicians refused.
In this survey, a small proportion of terminally ill patients seriously considered euthanasia or PAS for themselves. Over a few months, half the patients changed their minds. Patients with depressive symptoms were more likely to change their minds about desiring euthanasia or PAS. JAMA. 2000;284:2460-2468.
In 2002, an act regulating the ending of life by a physician at the request of a patient with unbearable suffering came into effect in the Netherlands. In 2005, we performed a follow-up study of euthanasia, physician-assisted suicide, and other end-of-life practices.
We mailed questionnaires to physicians attending 6860 deaths that were identified from death certificates. The response rate was 77.8%.
In 2005, of all deaths in the Netherlands, 1.7% were the result of euthanasia and 0.1% were the result of physician-assisted suicide. These percentages were significantly lower than those in 2001, when 2.6% of all deaths resulted from euthanasia and 0.2% from assisted suicide. Of all deaths, 0.4% were the result of the ending of life without an explicit request by the patient. Continuous deep sedation was used in conjunction with possible hastening of death in 7.1% of all deaths in 2005, significantly increased from 5.6% in 2001. In 73.9% of all cases of euthanasia or assisted suicide in 2005, life was ended with the use of neuromuscular relaxants or barbiturates; opioids were used in 16.2% of cases. In 2005, 80.2% of all cases of euthanasia or assisted suicide were reported. Physicians were most likely to report their end-of-life practices if they considered them to be an act of euthanasia or assisted suicide, which was rarely true when opioids were used.
The Dutch Euthanasia Act was followed by a modest decrease in the rates of euthanasia and physician-assisted suicide. The decrease may have resulted from the increased application of other end-of-life care interventions, such as palliative sedation.
To investigate the attitudes of terminally ill individuals toward the legalization of euthanasia or physician-assisted suicide (PAS) and to identify those who would personally desire such a death.
In the Canadian National Palliative Care Survey, semistructured interviews were administered to 379 patients who were receiving palliative care for cancer. Patients who expressed a desire for physician-hastened death were followed prospectively.
Attitudes toward the legalization of euthanasia or PAS were determined, as was the personal interest in receiving a hastened death. Demographic and clinical characteristics were also recorded, including a 22-item structured interview of symptoms and concerns.
There were 238 participants (62.8%) who believed that euthanasia and/or PAS should be legalized, and 151 (39.8%) who would consider making a future request for a physician-hastened death. However, only 22 (5.8%) reported that, if legally permissible, they would initiate such a request right away, in their current situations. This desire for hastened death was associated with lower religiosity (p=.010), reduced functional status (p=.024), a diagnosis of major depression (p<.001), and greater distress on 12 of 22 individual symptoms and concerns (p<.025). In follow-up interviews with 17 participants, 2 (11.8%) showed instability in their expressed desire.
Among patients receiving palliative care for cancer, the desire to receive euthanasia or PAS is associated with religious beliefs; functional status; and physical, social, and psychological symptoms and concerns. Although this desire is sometimes transitory, once firmly established, it can be enduring.
Aims and background
In Italy, euthanasia and assisted suicide remain illegal but have been the subject of constant debate. Such discussions, however, seem to take relatively little account of physicians' views and attitudes.
Methods and study design
We used an anonymous questionnaire to survey the attitudes and practices concerning euthanasia and the care of terminally ill patients of 5000 Italian physicians from among the approximately 20,000 members of seven of the most important Italian scientific societies. They were asked to complete an anonymous questionnaire consisting of 15 items, which also collected demographic and professional information.
Results
The response rate was 23.5%, and 855 questionnaires were returned. The respondents (75% males) had a median age of 51 years and 47% practiced medicine in a hospital or university setting. The survey showed that the attitude of Italian physicians towards caring for terminal patients is generally against the practice of euthanasia insofar as 84% and 87%, respectively, would, on a theoretical basis, be unwilling to prescribe or administer lethal drugs. Only 1.2-2% of the physicians declared that they had resorted at least once to active euthanasia practices consisting of the prescription and/or direct administration of lethal drugs during their professional lives, and 0.5–0.9% during the previous year. The main factor significantly influencing the opinions and behaviors of the physicians was religion.
Conclusions
To our knowledge, this is the first Italian survey investigating the opinions and practices on euthanasia of a large sample of physicians from all over the country, belonging to various medical specialties. Our findings confirm the considerable influence of religion on physician's opinions and practice concerning end-of-life care.
A survey about opinions on end-of-life issues of a population represented by 1,171 people in the waiting room of general practitioners' surgeries was conducted in a province of northern Italy. Most subjects did not consider suicide as a reasonable option even in cases of a serious and incurable disease. Moreover, subjects did not consider euthanasia as a possible option either; however, they did express an opposite attitude when considering euthanasia in a third-person perspective. People with a personal history of suicidal behavior appear to present as a different population, overall expressing more open attitudes.
Legal in some European countries and US states, physician-assisted suicide and voluntary active euthanasia remain under debate in these and other countries.
The aim of the study was to examine numbers, characteristics, and trends over time for assisted dying in regions where these practices are legal: Belgium, Luxembourg, the Netherlands, Switzerland, Oregon, Washington, and Montana.
This was a systematic review of journal articles and official reports. Medline and Embase databases were searched for relevant studies, from inception to end of 2012. We searched the websites of the health authorities of all eligible countries and states for reports on physician-assisted suicide or euthanasia and included publications that reported on cases of physician-assisted suicide or euthanasia. We extracted information on the total number of assisted deaths, its proportion in relation to all deaths, and socio-demographic and clinical characteristics of individuals assisted to die.
A total of 1043 publications were identified; 25 articles and reports were retained, including series of reported cases, physician surveys, and reviews of death certificates. The percentage of physician-assisted deaths among all deaths ranged from 0.1%-0.2% in the US states and Luxembourg to 1.8%-2.9% in the Netherlands. Percentages of cases reported to the authorities increased in most countries over time. The typical person who died with assistance was a well-educated male cancer patient, aged 60-85 years.
Despite some common characteristics between countries, we found wide variation in the extent and specific characteristics of those who died an assisted death.
We examined how acceptance of euthanasia among the general public has changed between 1981 and 2008 in western and central and eastern European (CEE) countries using data of the European Values Surveys. Data were collected in 1981, 1990, 1999 and 2008 for 13 western European countries and in 1990, 1999 and 2008 for 10 CEE countries. Euthanasia acceptance increased each decade up until 2008 in 11 of 13 western European countries; in CEE countries, it decreased or did not increase between 1999-2008 in 8 of 10 countries. A number of explanations for and implications of this apparent east-west polarization are suggested.
In Italy, euthanasia and assisted suicide remain illegal but have been the subject of constant debate. Such discussions, however, seem to take relatively little account of physicians' views and attitudes.
We used an anonymous questionnaire to survey the attitudes and practices concerning euthanasia and the care of terminally ill patients of 5000 Italian physicians from among the approximately 20,000 members of seven of the most important Italian scientific societies. They were asked to complete an anonymous questionnaire consisting of 15 items, which also collected demographic and professional information.
The response rate was 23.5%, and 855 questionnaires were returned. The respondents (75% males) had a median age of 51 years and 47% practiced medicine in a hospital or university setting. The survey showed that the attitude of Italian physicians towards caring for terminal patients is generally against the practice of euthanasia insofar as 84% and 87%, respectively, would, on a theoretical basis, be unwilling to prescribe or administer lethal drugs. Only 1.2-2% of the physicians declared that they had resorted at least once to active euthanasia practices consisting of the prescription and/or direct administration of lethal drugs during their professional lives, and 0.5-0.9% during the previous year. The main factor significantly influencing the opinions and behaviors of the physicians was religion.
To our knowledge, this is the first Italian survey investigating the opinions and practices on euthanasia of a large sample of physicians from all over the country, belonging to various medical specialties. Our findings confirm the considerable influence of religion on physician's opinions and practice concerning end-of-life care.
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.
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.
Cross-sectional survey.
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.
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.
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.
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.
Euthanasia is a debatable issue. It is illegal all over the world. The Netherlands is the only country where euthanasia and physician-assisted suicide are openly practised since the physician performing these acts will not be prosecuted under certain circumstances. There were several court cases and court decisions that affected the development of euthanasia and physician-assisted suicide in individual countries. When a patient asked for euthanasia, it was very important to find out the underlying reasons and make all legal means available to relieve the pain and other distressing symptoms.
Although euthanasia and physician-assisted suicide (PAS) are controversial issues, the views of those most affected, terminal patients, are seldom explored. Our objective was to assess whether the attitudes about euthanasia/PAS of terminally ill cancer patients were determined by their symptomatic distress.
We conducted a survey of 100 patients with terminal cancer. Statements related to the legalization of euthanasia/PAS were scored using Likert scales. We also asked patients how often they had considered ending their lives. Their responses were analyzed in relation to disease characteristics, including an assessment of symptomatic severity, sociodemographic features, general beliefs about the suffering of cancer patients, and survival.
Most patients (69%) supported euthanasia or PAS for one or more situations. The association between these attitudes and symptoms was weak, consistent in univariate analysis only for shortness of breath. No significant associations were observed with pain, nausea, well-being, loss of appetite, depression, or subsequent survival. Agreement with euthanasia was significantly related to male sex, lack of religious beliefs, and general beliefs about the suffering of cancer patients and their families. In multivariate analysis, the only characteristics that remained statistically associated with support were the strength of religious beliefs and the perception that patients with cancer are a heavy burden on their families. Frequency of suicidal ideation was associated with poor well-being, depression, anxiety, and shortness of breath, but not with other somatic symptoms such as pain, nausea, and loss of appetite.
Symptom intensity had limited impact on the attitudes about euthanasia of terminally ill cancer patients. Our findings suggest that patient views are primarily determined by psychosocial traits and beliefs, as opposed to disease severity or symptomatic distress.
Euthanasia and other end-of-life decisions are acceptable to the large majority of the Dutch public. Insight in the relationships of such acceptance, with characteristics considered important for a 'good death', may contribute to the understanding of this liberal attitude.
Questionnaires were mailed to 1777 members of the Dutch public (response: 78%), containing questions relating to a good death, attitudes towards euthanasia, terminal sedation and increasing morphine, and demographics. Associations between characteristics of a good death and attitudes towards these end-of-life decisions were analysed.
Characteristics that were considered important for a good death were: the possibility to say goodbye to loved ones (94%), dying with dignity (92%), being able to decide about end-of-life care (88%), and dying free of pain (87%). Acceptance of euthanasia, terminal sedation and increasing morphine were related to the wish to have a dignified death, and with concerns about burdening relatives with terminal care. Acceptance of euthanasia was also associated with the wish to be able to decide about medical end-of-life treatments and about the moment of death.
Besides saying farewell and dying pain free and with dignity, many members of the Dutch public consider values of control and maintenance of independence as important for a good death.
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