Euthanasia and Other Medical Decisions at the End of Life: Societal Control and Cultural Aspects

Death is a socially and culturally embedded phenomenon.1 It is inevitably understood and experienced within a complex web of cultural meanings that differ within and across countries. During the past century, acute death due to infectious diseases has to a great extent been replaced by death due to conditions that involve a more protracted dying process, such as cancer and cardiovascular diseases.2 Currently, approximately 70% of all deaths are non-sudden3 and are likely to involve some form of end-of-life care. Advances in medicine have greatly improved the possibilities to treat seriously ill patients and to prolong life and postpone death. It is also increasingly recognized that prolonging life is not always the most appropriate goal of medicine. Preserving quality of life and alleviating the patient’s suffering are other important care goals at the end of life. In some cases hastening of death can be an acceptable or even desired result of end of life care as well. Euthanasia, that is, deliberately ending a person’s life at the person’s request, and physician-assisted suicide, where the person self-administers lethal medication that is prescribed by a physician, are among the most controversial acts

Understanding provision of chemotherapy to patients with end stage cancer: qualitative interview study

Objective To examine health professionals’ experiences of and attitudes towards the provision of chemotherapy to patients with end stage cancer

Place of death and end-of-life transitions experienced by very old people with differing cognitive status: retrospective analysis of a prospective population-based cohort aged 85 and over.

BACKGROUND: Despite fast-growing 'older old' populations, 'place of care' trajectories for very old people approaching death with or without dementia are poorly described and understood. AIM: To explore end-of-life transitions of 'older old' people across the cognitive spectrum. DESIGN: Population-based prospective cohort (United Kingdom) followed to death. SETTING/PARTICIPANTS: Mortality records linked to 283 Cambridge City over-75s Cohort participants' cognitive assessments <1 year before dying aged ≥ 85 years. RESULTS: Overall, 69% were community dwelling in the year before death; of those with severe cognitive impairment 39% were community dwelling. Only 6% subsequently changed their usual address. However, for 55% their usual address on death registration was not their place of death. Dying away from the 'usual address' was associated with cognition, overall fewer moving with increasing cognitive impairment - cognition intact 66%, mildly/moderately impaired 55% and severely impaired 42%, trend p = 0.003. This finding reflects transitions being far more common from the community than from institutions: 73% from the community and 28% from institutions did not die where last interviewed (p < 0.001). However, severely cognitively impaired people living in the community were the most likely group of all to move: 80% (68%-93%). Hospitals were the most common place of death except for the most cognitively impaired, who mostly died in care homes. CONCLUSION: Most very old community-dwelling individuals, especially the severely cognitively impaired, died away from home. Findings also suggest that long-term care may play a role in avoidance of end-of-life hospital admissions. These results provide important information for planning end-of-life services for older people across the cognitive spectrum, with implications for policies aimed at supporting home deaths. MESH TERMS: Cognitive impairment, Dementia, Aged, 80 and over, Aged, frail elderly, Patient Transfer, Residential characteristics, Homes for the aged, Nursing Homes, Delivery of Health Care, Terminal care Other key phrases: Older old, Oldest old, Place of death, Place of care, End-of-life care

Clinical management of emotions in patients with cancer: introducing the approach "emotional support and case finding"

The current approach to the management of emotions in patients with cancer is "distress screening and referral for the provision of psychosocial care." Although this approach

Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study

Background: An important principle underlying the Dutch Euthanasia Act is physicians' responsibility to alleviate patients' suffering. The Dutch Act states that euthanasia and physician-assisted suicide are not punishable if the attending physician acts in accordance with criteria of due care. These criteria concern the patient's request, the patient's suffering (unbearable and hopeless), the information provided to the patient, the presence of reasonable alternatives, consultation of another physician and the applied method of ending life. To demonstrate their compliance, the Act requires physicians to report euthanasia to a review committee. We studied which arguments Dutch physicians use to substantiate their adherence to the criteria and which aspects attract review committees' attention. Methods: We examined 158 files of reported euthanasia and physician-assisted suicide cases that were approved by the review committees. We studied the physicians' reports and the verdicts of the review committees by using a checklist. Results: Physicians reported that the patient's request had been well-considered because the patient was clear-headed (65%) and/or had repeated the request several times (23%). Unbearable suffering was often substantiated with physical symptoms (62%), function loss (33%), dependency (28%) or deterioration (15%). In 35%, physicians reported that there had been alternatives to relieve patients' suffering which were refused by the majority. The nature of the relationship with the consultant was sometimes unclear: the consultant was reported to have been an unknown colleague (39%), a known colleague (21%), otherwise (25%), or not clearly specified in the report (24%). Review committees relatively often scrutinized the consultation (41%) and the patient's (unbearable) suffering (32%); they had few questions about possible alternatives (1%). Conclusion: Dutch physicians substantiate their adherence to the criteria in a variable way with an emphasis on physical symptoms. The information they provide is in most cases sufficient to enable adequate review. Review committees' control seems to focus on (unbearable) suffering and on procedural issues