Role of non-governmental organisations in physician assisted suicide

Could right to die organisations be part of the solution to the many ethical difficulties doctors face over assisted suicide? Stephen Ziegler and Georg Bosshard examine how two organisations in Switzerland and Oregon help people di

Suicide assisted by two Swiss right-to-die organisations

BACKGROUND: In Switzerland, non-medical right-to-die organisations such as Exit Deutsche Schweiz and Dignitas offer suicide assistance to members suffering from incurable diseases. OBJECTIVES: First, to determine whether differences exist between the members who received assistance in suicide from Exit Deutsche Schweiz and Dignitas. Second, to investigate whether the practices of Exit Deutsche Schweiz have changed since the 1990s. METHODS: This study analysed all cases of assisted suicide facilitated by Exit Deutsche Schweiz (E) and Dignitas (D) between 2001 and 2004 and investigated by the University of Zurich's Institute of Legal Medicine (E: n = 147; D: n = 274, total: 421). Furthermore, data from the Exit Deutsche Schweiz study which investigated all cases of assisted suicide during the period 1990-2000 (n = 149) were compared with the data of the present study. RESULTS: More women than men were assisted in both organisations (D: 64%; E: 65%). Dignitas provided more assistance to non-residents (D: 91%; E: 3%; p = 0.000), younger persons (mean age in years (SD): D: 64.5 (14.1); E: 76.6 (13.3); p = 0.001), and people suffering from fatal diseases such as multiple sclerosis and amyotrophic lateral sclerosis (D: 79%; E: 67%; p = 0.013). Lethal medications were more often taken orally in cases assisted by Dignitas (D: 91%; E: 76%; p = 0.000). The number of women and the proportion of older people suffering from non-fatal diseases among suicides assisted by Exit Deutsche Schweiz has increased since the 1990s (women: 52% to 65%, p = 0.031; mean age in years (SD): 69.3 (17.0) to 76.9 (13.3), p = 0.000), non-fatal diseases: 22% to 34%, p = 0.026). CONCLUSIONS: Weariness of life rather than a fatal or hopeless medical condition may be a more common reason for older members of Exit Deutsche Schweiz to commit suicide. The strong over-representation of women in both Exit Deutsche Schweiz and Dignitas suicides is an important phenomenon so far largely overlooked and in need of further study

Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians

BACKGROUND: Assisted suicide is permitted in Switzerland provided that assistance is not motivated by selfish reasons. Suicides are commonly performed with the assistance of right-to-die organisations and the use of a lethal dose of barbiturates prescribed by a participating physician. We examined the reasons physicians provided for writing the prescription and the reasons patients gave for requesting assistance in dying. METHODS: We analysed all reported cases of assisted suicide that were facilitated by right-to-die organisations between 2001 and 2004 in the city of Zurich, and for which both the medical report and the optional letter written by the decedent providing information on their reasons for seeking assistance in suicide (N = 165). RESULTS: The reasons most often reported by physicians (ph), as well as persons who sought help (p), were: pain (ph: 56% of all assisted suicides, p: 58%), need for long-term care (ph: 37%, p: 39%), neurological symptoms (ph: 35%, p: 32%), immobility (ph: 23%, p: 30%) and dyspnoea (ph: 23%, p: 23%). Control of circumstances over death (ph: 12%, p: 39%); loss of dignity (ph: 6%, p: 38%); weakness (ph: 13%, p: 26%); less able to engage in activities that make life enjoyable (ph: 6%, p: 18%); and insomnia and loss of concentration (ph: 4%, p: 13%) were significantly more often mentioned by decedents than by physicians. CONCLUSIONS: Both prescribing physicians and;patients provided with assistance to die quite often mentioned pain and other concerns, many of which were objectively assessable and related to unbearable suffering or unreasonable disability. Concerns referable to autonomy and individual judgement were more often noted by people seeking help than by the prescribing physicians

Continuous deep sedation until death in patients admitted to palliative care specialists and internists: a focus group study on conceptual understanding and administration in German-speaking Switzerland

BACKGROUND Continuous deep sedation until death is increasingly used to treat intolerable suffering of terminally ill patients. One of the highest incidences and strongest increases has been observed in Switzerland. Variation in prevalence estimates indicates a potential effect of differences in sedation practice between care settings and professionals. AIM To explore physicians' and nurses' conceptual understanding of continuous deep sedation and unravel decision-making processes in everyday clinical practice. METHODS Between June and October 2016, we conducted seven qualitative focus groups with 47 healthcare professionals (21 physicians and 26 nurses) involved in sedation decision and administration. RESULTS Participants had on average 20 years (range 3-39) of clinical experience, 10 years (range 0-30) of self-reported palliative care experience, and a mean annual number of 5 patients (range 1-20) continuously deeply sedated until death. Continuous deep sedation until death covers a wide spectrum of practices: specialised palliative sedation induced through benzodiazepines to treat refractory symptoms as option of last resort, sedation as comfort therapy with benzodiazepines or opioids, and sedation taken into account as a side effect of gradually increased analgesia. CONCLUSION We found substantial variation in terminology and definition, indication and medication used for continuous deep sedation until death. To provide optimal symptom management in terminally ill patients, early involvement of palliative care experts as well as financial and regulatory support should be provided to encourage multi-disciplinary collaboration and thus consensus for defining the distinct sedation practices

Using sedative substances until death: A mortality follow-back study on the role of healthcare settings

BACKGROUND: In the last decade, the use of sedative substances to keep a patient in deep sedation until death increased fourfold in German-speaking Switzerland, where every third patient admitted to hospital, palliative care unit or hospice died continuously deeply sedated. AIM: To investigate sedation practices across healthcare settings and to identify their associations with conventional symptom control. DESIGN: National mortality follow-back study in Switzerland between 2013 and 2014. Questionnaires on medical end-of-life decisions were sent to attending physicians of a continuous random sample of all registered deaths aged 1 year or older. SETTING/PARTICIPANTS: Of all sampled deaths, 3678 individuals who died non-suddenly and not through an external cause were included. RESULTS: Across settings, continuous deep sedation appeared more likely in patients aged younger than 65 years (odds ratio range: 1.53-2.34) and as part of or after intensified alleviation of pain and symptoms (odds ratio range: 1.90-10.27). In hospitals, sedation was less likely for cancer patients (odds ratio: 0.7, 95% confidence interval: 0.5-1.0, p = 0.022). In nursing homes, sedation was more likely for people who were married (odds ratio: 1.8, 95% confidence interval 1.3-2.5, p = 0.001). CONCLUSION: In all settings, sedated patients have significantly more pain problems compared to patients not receiving sedation. Large differences between settings seem to indicate different patient populations, different levels of professionals' palliative care experience and different availability of treatment options. Our study suggests that certain patient groups who may be as vulnerable to refractory pain and symptoms as others are less likely to receive continuous deep sedation until death when warranted

Continuous Deep Sedation Until Death - a Swiss Death Certificate Study

Background In the last decade, the number of patients continuously deeply sedated until death increased up to fourfold. The reasons for this increase remain unclear. Objective To identify socio-demographic and clinical characteristics of sedated patients, and concurrent possibly life-shortening medical end-of-life decisions. Design Cross-sectional death certificate study in German-speaking Switzerland in 2001 and 2013. Participants Non-sudden and expected deaths (2001: N = 2281, 2013: N = 2256) based on a random sample of death certificates and followed by an anonymous survey on end-of-life practices among attending physicians. Main measures Physicians’ reported proportion of patients continuously deeply sedated until death, socio-demographic and clinical characteristics, and possibly life-shortening medical end-of life decisions. Key results In 2013, physicians sedated four times more patients continuously until death (6.7% in 2001; 24.5.5% in 2013). Four out of five sedated patients died in hospitals, outside specialized palliative care units, or in nursing homes. Sedation was more likely among patients younger than 65 (odds ratio 2.24, 95% CI 1.6 to 3.2) and those dying in specialized palliative care (OR 2.2, 95% CI 1.3 to 3.8) or in hospitals (1.7, 95% CI 1.3 to 2.3). Forgoing life-prolonging treatment with the explicit intention to hasten or not to postpone death combined with intensified alleviation of symptoms was very strongly associated with continuous deep sedation (OR 6.8, 95% CI 4.7 to 9.8