Associations of end-of-life preferences and trust in institutions with public support for assisted suicide evidence from nationally representative survey data of older adults in Switzerland

The legality of euthanasia and assisted suicide (AS) and nature of regulations of these practices remain controversial and the subject of lively debate among experts and the general public. Our study investigates attitudes and behaviours towards AS among older adults in Switzerland where the practice of AS has a relatively long history and remains rather unregulated. We aim to explore how individuals' preferences regarding their end of life, as well as individuals' trust in institutions involved in the practice or control of AS are associated with attitudes and behaviours towards AS. We analyse nationally representative data of adults aged 55 and over from wave 6 (2015) of the Survey of Health, Ageing and Retirement in Europe (SHARE) in Switzerland (n = 2,145). While large majorities supported current legal arrangements around AS in Switzerland (81.7%) and stated that they could consider AS for themselves under certain circumstances (61.0%), only a minority either was a member of a right-to-die organisation already (4.9%) or stated they were likely to become a member of such an organisation (28.2%). Stated preferences for control over the end of life and for maintaining essential capabilities at the end of life showed a positive association with AS-related attitudes and behaviours, whereas preferences for feeling socially and spiritually connected, as well as for not being a burden displayed a negative association with our outcomes. Higher levels of trust in one's relative were positively associated with both support for the legality of AS and potential use of AS. A positive association was also found between trust in the Swiss legal system and support for the legality of AS. By contrast, trust in religious institutions displayed a negative association with all five AS-related attitudes and behaviours. Similarly, trust in healthcare insurance companies was negatively associated with potential use of AS. Taken together, older adults were generally supportive towards current practices regarding AS. This approval appears to be closely related to individuals' preferences and, at different extends, to trust in social and public institutions with regard to end-of-life issues, which is relatively high in Switzerland

Awareness, approval and completion of advance directives in older adults in Switzerland

Advance directives enable people to describe their preferences for medical treatment (living will) and/or to appoint a healthcare proxy who may decide on their behalf should they lose decision-making capacity. Advance directives are potentially important in determining the course of end-of-life care, as deaths are frequently preceded by end-of-life treatment decisions, which often require someone to make decisions on the patient's behalf. Switzerland introduced legally binding advance directives through its new child and adult protection law of 2013. But there is still no comprehensive evidence on older persons' awareness, attitudes and behaviours with regard to advance directives in Switzerland. Our study aimed to assess levels of awareness, approval and completion of advance directives, as well as their respective associations with sociodemographic characteristics in the Swiss population aged 55 and older. Our study was cross-sectional and used data from the Survey of Health, Ageing and Retirement in Europe (SHARE), which included a special module on end-of-life issues in wave 6 (2015) in Switzerland (n = 2085). Two years after the introduction of advance directives in Switzerland, 78.7% of adults aged 55 years and older had heard of them prior to the survey and 24% reported that they had completed one. Awareness of advance directives was higher in the German-speaking part of Switzerland (91%) than in the Italian- (57.1%) and French-speaking (43.3%) regions (p <0.001). Advance directive completion also differed significantly between the German- (28.7%), French- (10.3%) and Italian-speaking (17.9%) regions of Switzerland (p <0.001). Overall, 76.7% of Swiss adults aged 55 and older generally approved of advance directives, i.e., they either reported having already completed one or were planning to do so in the future. Of those who had not yet completed an advance directive, 32.9% believed that it was still "too early" for them to do so and 30.1% believed that they would not need one. Levels of awareness, approval and completion of advance directives also varied significantly by sex, age, education level and household composition. Our results show some potential for improvement in levels of advance directive awareness and, especially, completion among older adults, notably in the French- and Italian-speaking Switzerland. In view of the generally high levels of approval of advance directives, our findings point to important barriers to their completion by older persons that should be addressed by policy makers in order to ensure an effective translation of individual intentions to complete an advance directive sometime in the future into concrete and timely actions toward this end

Public opinion on the smoking ban: The impact of mass media, interpersonal communication and intrapersonal variables

This dissertation examines individual opinion formation in the context of the smoking ban that was voted in Ticino in March 2006 using a complex model that includes selfinterest, political predispositions, media use, interpersonal discussion and perception of community support for the policy proposal. These variables were assumed to impact individual's belief systems (salience of the different arguments and beliefs about the smoking ban) which in turn would determine recipients' opinion on the smoking ban. Self-interest, political predisposition, media use, interpersonal discussion, perceived support and belief systems were measured in a longitudinal opinion survey. In parallel, a content analysis examined the coverage of the debate on the smoking ban. Hypotheses related to media impact were formulated on the basis of the results of the content analysis. The results from the structural equation modeling (SEM) analyses revealed that self-interest, interpersonal discussion and perceived support were important predictors. Their impact on general opinion about the smoking ban was principally mediated by beliefs about the smoking ban. In contrast, media exposure did not significantly impact opinion formation. Several explanations for the lack of media effect are discussed in the conclusion

Correction: Associations of end-of-life preferences and trust in institutions with public support for assisted suicide: Evidence from nationally representative survey data of older adults in Switzerland.

[This corrects the article DOI: 10.1371/journal.pone.0232109.]

Development and validation of a subjective end-of-life health literacy scale.

Personal health literacy is the ability of an individual to find, understand, and use information and services to inform health-related decisions and actions for oneself and others. The end of life is commonly characterized by the occurrence of one or several diseases, the use of many different types of healthcare services, and a need to make complex medical decisions that may involve challenging tradeoffs, such as choices between quality and length of life. Although end-of-life care issues concern most people at some point in life, individuals' competencies to deal with those questions have rarely been explored. This study aims to introduce, develop, and validate an instrument to measure individuals' self-assessed competencies to deal with end-of-life medical situations, the Subjective End-Of-Life Health Literacy Scale (S-EOL-HLS), in a sample of older adults aged 50+ living in Switzerland who participated in wave 8 (2019/2020) of the Survey of Health, Ageing, and Retirement in Europe. The S-EOL-HLS uses a series of questions on self-rated difficulties in understanding end-of-life medical jargon, defining in advance which end-of-life medical treatments to receive or refuse, and communicating related choices. Aside from conducting exploratory and confirmatory factor analysis to evaluate the construct validity, we compared measurements from the S-EOL-HLS to respondents' general health literacy measured with the European Health Literacy Survey questionnaire. We obtained a three-factor model with acceptable fit properties (CFI = 0.993, TLI = 0.992, RMSEA = 0.083, SRMR = 0.061) and high reliability (α = 0.93). The partial associations between the health literacy scores from the two scales and respondents' sociodemographic characteristics were similar; however, individuals with higher end-of-life health literacy scores appeared to have more positive attitudes towards end-of-life care planning outcomes. The S-EOL-HLS demonstrates reliable and consistent results, making the instrument suitable for older adults in population surveys

Association between multiple chronic conditions and insufficient health literacy: cross-sectional evidence from a population-based sample of older adults living in Switzerland

BACKGROUND: Health literacy is the ability to find, understand, assess, and apply health information. Individuals suffering from multiple chronic conditions have complex healthcare needs that may challenge their health literacy skills. This study aimed to investigate the relationship between multimorbidity, the number of chronic conditions, and health literacy levels in a sample of adults aged 58+ in Switzerland. METHODS: We used data from 1,615 respondents to a paper-and-pencil questionnaire administered as part of wave 8 (2019/2020) of the Survey of Health, Ageing and Retirement in Europe (SHARE) in Switzerland. Health literacy was measured using the short version of the European Health Literacy Survey questionnaire. The final score ranged from 0 to 16 and was categorised into three health literacy levels: inadequate (0–8), problematic (9–12), and sufficient (13–16). The number of chronic conditions was self-reported based on a pre-defined list. Associations were examined using multivariable ordinary least squares and ordered probit regression models, controlling for key socio-demographic characteristics. RESULTS: Overall, 63.5% of respondents reported having at least one chronic condition. Respondents who reported one, two, and three or more chronic conditions were more likely to have lower health literacy scores compared to respondents who did not report any chronic condition (p<0.05, p<0.01, and p<0.001, respectively). Suffering from two and three or more chronic conditions (vs. no chronic condition) was significantly associated with a higher likelihood of having inadequate or problematic health literacy levels (both p-values <0.01). CONCLUSIONS: Our findings suggest a need to improve health literacy in older adults suffering from chronic conditions. Improved health literacy could constitute a promising lever to empower individuals to better self-manage their health to ultimately reduce the double burden of chronic diseases and insufficient health literacy in this vulnerable population. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12889-023-15136-6