Georg Bosshard

Do-not-resuscitate decisions in six European countries

Objective:To study and compare the incidence and main background characteristics of do-not-resuscitate (DNR) decision making in six European countries. Design:Retrospective. Setting:We studied DNR decisions simultaneously in Belgium (Flanders), Denmark, Italy (four regions), the Netherlands, Sweden, and Switzerland (German-speaking part). In each country, random samples of death certificates were drawn from death registries to which all deaths are reported. The deaths occurred between June 2001 and February 2002. Participants:Reporting physicians received a mailed questionnaire about the medical decision making that had preceded death. The response percentage was 75% for the Netherlands, 67% for Switzerland, 62% for Denmark, 61% for Sweden, 59% for Belgium, and 44% for Italy. The total number of deaths studied was 20,480. Interventions:None. Measurements and Main Results:Measurements were fre-quency of DNR decisions, both individual and institutional, and patient involvement. Before death, an individual DNR decision was made in about 50–60% of all nonsudden deaths (Switzerland 73%, Italy 16%). The frequency of institutional decisions was highest in Sweden (22%) and Italy (17%) and lowest in Belgium (5%). DNR decisions are discussed with competent patients in 10–84% of cases. In the Netherlands patient involvement rose from 53% in 1990 to 84% in 2001. In case of incompetent patients, physicians bypassed relatives in 5–37% of cases. Conclusions:Except in Italy, DNR decisions are a common phenomenon in these six countries. Most of these decisions are individual, but institutional decisions occur frequently as well. In most countries, the involvement of patients in DNR decision making can be improved.

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.

A role for doctors in assisted dying? An analysis of legal regulations and medical professional positions in six European countries

Objectives: To analyse legislation and medical professional positions concerning the doctor’s role in assisted dying in western Europe, and to discuss their implications for doctors. Method: This paper is based on country-specific reports by experts from European countries where assisted dying is legalised (Belgium, The Netherlands), or openly practiced (Switzerland), or where it is illegal (Germany, Norway, UK). Results: Laws on assisted dying in The Netherlands and Belgium are restricted to doctors. In principle, assisted suicide (but not euthanasia) is not illegal in either Germany or Switzerland, but a doctor’s participation in Germany would violate the code of professional medical conduct and might contravene of a doctor’s legal duty to save life. The Assisted Dying for the Terminally Ill Bill proposed in the UK in 2005 focused on doctors, whereas the Proposal on Assisted Dying of the Norwegian Penal Code Commission minority in 2002 did not. Professional medical organisations in all these countries except The Netherlands maintain the position that medical assistance in dying conflicts with the basic role of doctors. However, in Belgium and Switzerland, and for a time in the UK, these organisations dropped their opposition to new legislation. Today, they regard the issue as primarily a matter for society and politics. This “neutral” stance differs from the official position of the Royal Dutch Medical Association which has played a key role in developing the Dutch practice of euthanasia as a “medical end-of-life decision” since the 1970s. Conclusion: A society moving towards an open approach to assisted dying should carefully identify tasks to assign exclusively to medical doctors, and distinguish those possibly better performed by other professions.

Responders and non-responders in a study on medical end-of-life decisions in Denmark, the Netherlands, Sweden and Switzerland.

Summary.Objectives: To determine the direction and magnitude of participation bias in end-of-life research. Methods: Within the framework of a European survey on medical end-of-life decisions, a non-response study was conducted among physicians in Denmark, the Netherlands, Sweden and Switzerland. People were asked about their attitudes and experiences in the area of medial end-of-life decision. The response rates ranged from 12.8% (Netherlands) to 39.4% (Switzerland). The responders (n = 5 403) and the non-responders (n = 866) were compared regarding socio-demographic characteristics, experiences with terminal patients and agreement with attitudes towards “end-of-life decisions”. The reasons for non-participation to the study were analyzed. Results: Non-response did not cause socio-demographic distortion, but non-responders had statistically significantly fewer terminal patients than responders. Agreement rates were statistically significantly higher among responders than among non-responders for euthanasia, non-treatment decision and life-preserving statements. Neutral answers were statistically significantly more frequent among non-responders than among responders for life-preserving and euthanasia statements. The most commonly mentioned reason for non-participation was “lack of time”. Conclusion: Non-participation does cause an overestimation of proponents of life-shortening, as well as of life-preserving end-of-life decisions. Non-responders more often have ambiguous attitudes towards end-of-life decisions than responders.Zusammenfassung.Antwortende und Nicht-Antwortende in einer Studie zu medizinischen Entscheidungen am Lebensende in Dänemark, Holland, Schweden und der SchweizFragestellung: Richtung und Ausmaß von Teilnahmeverzerrungen in der Sterbehilfeforschung sollen bestimmt werden. Methoden: Im Rahmen eines europäischen Forschungsprojektes zu medizinischen Entscheidungen am Lebensende wurde bei ärztinnen und ärzten in Dänemark, Holland, Schweden und in der Schweiz eine Non-response Studie durchgeführt. Die Personen wurden nach ihren Einstellungen zu und Erfahrungen mit medizinischen Entscheidungen am Lebensende befragt. Der Rücklauf reichte von 12.8% in Holland bis zu 39.4% in der Schweiz. Antwortende (n = 5 403) und Nichtantwortende (n = 866) wurden hinsichtlich soziodemographischer Merkmale, Erfahrungen mit sterbenden Patientinnen und Patienten und der Zustimmung zu Einstellungen gegenüber Entscheidungen am Lebensende verglichen. Im Weiteren wurden die Gründe für die Nicht-Teilnahme an der Hauptbefragung untersucht. Ergebnisse: Nicht-Teilnahme führt zu keinen soziodemographischen Verzerrungen, jedoch betreuten die Nichtantwortenden in Holland, der Schweiz und allen vier Ländern zusammen signifikant weniger sterbende Patientinnen und Patienten als die Antwortenden. Die Zustimmung zu den Statements über aktive Sterbehilfe und über passive Sterbehilfe wie auch zum Statement zur Lebenserhaltung unter allen Umständen fiel unter den Antwortenden signifikant höher aus als unter den Nichtantwortenden. Hinsichtlich der Lebenserhaltung unter allen Umständen sowie der aktiven Sterbehilfe waren neutrale Antworten unter den Nichtantwortenden signifikant häufiger als bei den Antwortenden. Als häufigster Grund für die Nicht-Teilnahme wurde “Zeitmangel” genannt. Schlussfolgerung: Die Nicht-Teilnahme führt zu einer überrepräsentation der Befürwortenden sowohl von lebensverkürzenden als auch von lebenserhaltenden Entscheidungen. Nichtantwortende haben häufiger unklare Einstellungen gegenüber Entscheidungen am Lebensende als Antwortende.Résumé.Répondants et non-répondants dans une étude sur les décisions médicales en fin de vie au Danemark, aux Pays-Bas, en Suède et en SuisseObjectifs: Déterminer la nature et l’importance de biais de participation dans la recherche sur l’euthanasie. Méthode: Dans le cadre d’une recherche européenne sur les décisions médicales euthanasiques, une étude des non-réponses a été réalisée auprès de médecins au Danemark, aux Pays-bas, en Suède et en Suisse. Les questions abordaient les attitudes et l’expérience des médecins face à des décisions euthanasiques. Les taux de réponses varient de 12.8 (Pays-Bas) à 39.4% (Suisse). Les répondants (n = 5 403) et les non-répondants (n = 866) ont été comparés selon leurs caractéristiques socio-démographiques, leurs expériences avec des patients en phase terminale et leurs attitudes face à l’euthanasie. Les raisons d’une non-participation à l’étude ont été analysées. Résultats: Les non-réponses n’ont pas causé de déformation socio-démographique, cependant la catégorie des non-répondants compte de manière statistiquement significative moins de patients en phase terminale que la catégorie des répondants aux Pay-bas, en Suisse et dans l’ensemble des quatre pays. Le taux d’approbation d’affirmations sur le thème de l’euthanasie active et passive et du maintien de la vie était significativement plus élevé parmi les répondants que parmi les non-répondants. Les réponses neutres sur le thème du maintien de la vie et de l’euthanasie étaient plus souvent apportées par les non-répondants. Le «manque de temps» a été la cause de non-participation la plus souvent invoquée. Conclusion: La non-participation induit une surestimation des partisans de l’euthanasie, aussi bien que des partisans du maintien de la vie. Plus souvent que les répondants, les nonrépondants ont des points de vue ambigus envers les décisions d’euthanasie.

Der Sterbeort: „Wo sterben die Menschen heute in der Schweiz?“

ZusammenfassungHintergrundAmtliche Informationen zum Sterbeort werden seit 1987 im Bundesamt für Statistik (BfS) nicht mehr erhoben. Somit können aus dieser Quelle für die Schweiz keine Aussagen über die Entwicklung des Sterbeortes gemacht werden.MethodenMittels eines Fragebogens wurden Ärztinnen und Ärzte aus der Deutsch-Schweiz, welche zwischen dem 1. Juni und dem 30. Oktober 2001 ein Todesfallformular unterzeichneten, zum konkreten Todesfall schriftlich befragt. Die Häufigkeitsverteilungen zum Sterbeort (zu Hause, im Spital, Alters-, Pflege- und Krankenheim, anderer Ort) werden mit den amtlichen Daten zum Sterbeort für die Jahre 1969 bis 1986 verglichen. Anhand logistischer Regressionen werden die Einflussgrößen für die Sterbeorte identifiziert.ErgebnisseDer Tod ereignete sich im Jahre 2001 in der Deutsch-Schweiz am häufigsten im Spital (37,2% der Todesfälle). Am zweit häufigsten fand der Tod im Alters-, Kranken- oder Pflegeheim statt (33,5%) und an dritter Stelle stand das Sterben zu Hause (22,7%). Determinanten für den Sterbeort waren die Todesursache, das Geschlecht, der Zivilstand und teilweise die Religion. Während sich zwischen 1969 und 1986 eine Entwicklung zum institutionellen Sterben abzeichnete, verlagerte sich zwischen 1986 und 2001 das Sterben innerhalb der Institutionen von den Spitälern weg in die Alters- und Pflegeheime.SchlussfolgerungDie Bedeutung der Alters- und Pflegeheime als Sterbeort dürfte in Zukunft noch stärker wachsen, da in der kommenden Zeit der Anteil von alten Menschen ansteigen wird. Um Personen zu ermöglichen, die Pflege- und Betreuungsaufgaben von Angehörigen zu Hause erfüllen zu können, müssten die ambulanten Hilfsdienste erhöht werden und Anreize geschaffen und Unterstützungen geboten werden.SummaryBackgroundOfficial information on the place of death has not been collected by the Swiss Federal Office of Statistics since 1987. Thus, no statements can be made for the developments in Switzerland.MethodsPhysicians from the German speaking part of Switzerland who had filled in a death certificate between June 1 and October 30, 2001 were sent a questionnaire about circumstances of the specific death case. The frequencies of the place of death (at home, in hospital, in home for elderly, in nursing home, other place) were compared with the official data of the years 1969 until 1986. Using logistic regressions predictors for the place of death were estimated.ResultsIn 2001 in the German speaking part of Switzerland death occurred most frequently in hospital (37.2% of all death cases) followed by a home for elderly (33.5%) and dying at home (22.7%). Relevant predictors for the place of death were cause of death, sex, marital status and partly religion. Whereas between 1969 and 1986 a development towards dying in institutions was found, between 1986 and 2001 the place of death shifted within the institutions from hospitals to homes for elderly.ConclusionThe relevance of the home for elderly as the place of death will further grow in the future. To allow people to fulfill the tasks of caring for their relatives at home the ambulant emergency services will have to be augmented and relatives have to be motivated and supported.

Breast cancer in women 80 years of age and older: A comprehensive analysis of an underreported entity

Abstract Background. Approximately 10% of breast cancer (BC) patients are over the age of 80. We present the first comprehensive review on this particular group of patients. Patients and methods. The treatments and disease courses of an unselected cohort of patients, whose age at first diagnosis was ≥ 80 years (n = 151), were compared to those of a group of women, who were aged 56–66 years (n = 372). Results. The group of elderly patients had larger tumors at first diagnosis (25 mm vs. 18 mm, p < 0.001) and higher disease stages (I: 31.1% vs. 44.1%, IV: 11.9% vs. 5.4%; each p < 0.001). There were no significant differences between both groups in terms of histologic subtype, grading, hormonal receptor status and HER2 status. The tumors of older patients were more often detected by clinical examination (38.9% vs. 17.0%, p < 0.001) and less often by mammography/sonography (10.4% vs. 29.9%, p < 0.001). The rate of patients who died of BC were similar in both groups (21.2% vs. 21.5%, p = 1.00). In the patients who had no evidence of metastases and who opted for primary non-surgical management (n = 21), the tumor could be stabilized without considerable morbidity in only 42.9%. Persistence to adjuvant endocrine therapy was comparable (83.0% vs. 88.3%, p = 0.357). In the adjuvant as well as in the palliative settings, elderly patients received less chemotherapy than younger ones (adjuvant: 1.6% vs. 23.3%; palliative: 32.3% vs. 68.4%; each p < 0.001). For palliative treatments only, elderly patients received fewer treatment regimens (≥ 3 therapy lines: 16.0% vs. 54.9%, p < 0.001). In those patients who died of BC, elderly women had inferior overall (25 vs. 54.5 months, p < 0.001) as well as metastatic-disease survival (11.5 vs. 19 months, p = 0.062). Conclusion. It must be ensured that appropriate standard therapies should not be routinely withheld in older patients based on erroneous perceptions regarding the biological nature of BC in the elderly and lack of knowledge about available therapy regimens. Physicians should consider that preservation of current life circumstances and maintenance of quality of life are frequently more important than “classical” hard medical facts such as survival times.

Assessment of Requests for Assisted Suicide by a Swiss Right-to-Die Society

Non-physician volunteers of Exit, the largest right-to-die organization in Switzerland, play an important role in assisted suicide. They conduct assessments and deliver lethal medications for a member to self-administer. This study analyses the content of 114 intake sheets (checklists) of Exit members whose requests for assisted suicide were granted in an effort to examine the frequency of depression and whether their relatives agreed with the members decision to commit suicide (2 questions that can help increase the likelihood that the members decision was both informed and voluntary). Exits paperwork indicated that depression was found to exist in 27% of the cases, was more common among those under 65, and relatives explicitly disagreed with the members decision in 5% of the cases.

Place of death: "Where do people die in Switzerland nowadays?"

ZusammenfassungHintergrundAmtliche Informationen zum Sterbeort werden seit 1987 im Bundesamt für Statistik (BfS) nicht mehr erhoben. Somit können aus dieser Quelle für die Schweiz keine Aussagen über die Entwicklung des Sterbeortes gemacht werden.MethodenMittels eines Fragebogens wurden Ärztinnen und Ärzte aus der Deutsch-Schweiz, welche zwischen dem 1. Juni und dem 30. Oktober 2001 ein Todesfallformular unterzeichneten, zum konkreten Todesfall schriftlich befragt. Die Häufigkeitsverteilungen zum Sterbeort (zu Hause, im Spital, Alters-, Pflege- und Krankenheim, anderer Ort) werden mit den amtlichen Daten zum Sterbeort für die Jahre 1969 bis 1986 verglichen. Anhand logistischer Regressionen werden die Einflussgrößen für die Sterbeorte identifiziert.ErgebnisseDer Tod ereignete sich im Jahre 2001 in der Deutsch-Schweiz am häufigsten im Spital (37,2% der Todesfälle). Am zweit häufigsten fand der Tod im Alters-, Kranken- oder Pflegeheim statt (33,5%) und an dritter Stelle stand das Sterben zu Hause (22,7%). Determinanten für den Sterbeort waren die Todesursache, das Geschlecht, der Zivilstand und teilweise die Religion. Während sich zwischen 1969 und 1986 eine Entwicklung zum institutionellen Sterben abzeichnete, verlagerte sich zwischen 1986 und 2001 das Sterben innerhalb der Institutionen von den Spitälern weg in die Alters- und Pflegeheime.SchlussfolgerungDie Bedeutung der Alters- und Pflegeheime als Sterbeort dürfte in Zukunft noch stärker wachsen, da in der kommenden Zeit der Anteil von alten Menschen ansteigen wird. Um Personen zu ermöglichen, die Pflege- und Betreuungsaufgaben von Angehörigen zu Hause erfüllen zu können, müssten die ambulanten Hilfsdienste erhöht werden und Anreize geschaffen und Unterstützungen geboten werden.SummaryBackgroundOfficial information on the place of death has not been collected by the Swiss Federal Office of Statistics since 1987. Thus, no statements can be made for the developments in Switzerland.MethodsPhysicians from the German speaking part of Switzerland who had filled in a death certificate between June 1 and October 30, 2001 were sent a questionnaire about circumstances of the specific death case. The frequencies of the place of death (at home, in hospital, in home for elderly, in nursing home, other place) were compared with the official data of the years 1969 until 1986. Using logistic regressions predictors for the place of death were estimated.ResultsIn 2001 in the German speaking part of Switzerland death occurred most frequently in hospital (37.2% of all death cases) followed by a home for elderly (33.5%) and dying at home (22.7%). Relevant predictors for the place of death were cause of death, sex, marital status and partly religion. Whereas between 1969 and 1986 a development towards dying in institutions was found, between 1986 and 2001 the place of death shifted within the institutions from hospitals to homes for elderly.ConclusionThe relevance of the home for elderly as the place of death will further grow in the future. To allow people to fulfill the tasks of caring for their relatives at home the ambulant emergency services will have to be augmented and relatives have to be motivated and supported.

Prophylaxis of Heterotopic Ossification in Patients Sedated after Polytrauma

Background and Purpose:Heterotopic ossification (HO) often follows acetabular fractures after multitrauma. Irradiation is a mean for prophylaxis. We established a standard procedure in our hospital for patients under sedation, when obtaining informed consent for HO prophylaxis is impossible.Patients and Methods:We reviewed current scientific evidence, calculated the risks of radiation and presented the ethical and legal framework. The subject was scrutinised by an interdisciplinary panel.Results:Irradiation is the most effective means for prophylaxis and has few adverse effects in adult patients with fractures of the acetabulum. The lifetime risk of radiation-induced cancer or infertility are insignificant.Conclusions:Informed consent for irradiation should be obtained before operation whenever possible. When this cannot be done prophylaxis can be postponed for a maximum of 3 days in order to obtain consent. If the patient is not able to communicate within this period, prophylactic irradiation should be given after consulting the relatives. The patient must be informed as soon as possible.Hintergrund und Ziel:Heterotope Ossifikationen (HO) entstehen häufig nach Acetabulumfrakturen. Übliche Methode der HOProphylaxe ist die Bestrahlung. Ziel unserer Arbeit war die Erarbeitung einer standardisierten Vorgehensweise bei sedierten Patienten.Patienten und Methodik:Der medizinische Kenntnisstand, rechtliche und ethische Aspekte wurden zusammengetragen und Berechnungen für strahleninduzierte Risiken durchgeführt. Auf dieser Basis wurde die Thematik von einer interdisziplinären Expertengruppe diskutiert.Ergebnisse:Die Bestrahlung bei Patienten mit Acetabulumfraktur ist effektiv und risikoarm. Das Lebenszeitrisiko zur Entwicklung eines strahleninduzierten Malignoms ist gering. Es besteht kein Infertilitätsrisiko.Schlussfolgerungen:Ist die Zustimmung des Patienten zur prophylaktischen Bestrahlung präoperativ nicht einholbar und der Patient auch postoperativ nicht aufklärbar, werden Aufklärung und Bestrahlung bis drei Tage nach der Operation aufgeschoben. Ist der Patient weiterhin nicht aufklärbar, wird nach Rücksprache mit den Angehörigen die prophlyaktische Bestrahlung durchgeführt. Die Aufklärung des Patienten wird baldmöglichst nachgeholt.

Chemotherapy near the end of life: a retrospective single-centre analysis of patients'charts

BackgroundChemotherapy near the end of life is an issue frequently discussed nowadays. The concern is that chemotherapy could cause more harm than good in a palliative situation; this is even truer as the patient nears death. The objective of our study is to evaluate the aggressiveness of patient care near the end of life by determining how many cancer patients receive chemotherapy during their final weeks.MethodsIn a retrospective analysis of patient charts, we investigated whether cancer patients had been treated with chemotherapy during the last four or two weeks of life. If they had, we looked at whether treatment was ongoing or newly initiated.ResultsOut of the 119 cancer patients who died in our hospital over two years, 14 (11.7%) received chemotherapy during the last four weeks of life, nine of whom (7.6%) in the last two weeks of life. Treatment had been ongoing in six (5%) and newly initiated for eight (6.7%) within four weeks of death. Corresponding figures for the last two weeks of life were seven patients (5.9%) who continued previously prescribed treatment and two (1.7%) who were started on chemotherapy. Patients given chemotherapy during the last four weeks of life were significantly younger than those who were not (p = 0.003).ConclusionsCancer patient care in our hospital is not considered overly aggressive as only 7.6% of these patients receive chemotherapy within the last two weeks of life. To determine how aggressive care near the end of life really is, however, we suggest evaluating newly started chemotherapy alongside ongoing treatment. As the line between the effects (beneficience) and side effects (nonmaleficience) of chemotherapy is often very narrow, doctors and patients have to work together to find the best way of treading this fine line.