Joachim Cohen

Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe

IMPORTANCEnThe increasing legalization of euthanasia and physician-assisted suicide worldwide makes it important to understand related attitudes and practices.nnnOBJECTIVEnTo review the legal status of euthanasia and physician-assisted suicide and the available data on attitudes and practices.nnnEVIDENCE REVIEWnPolling data and published surveys of the public and physicians, official state and country databases, interview studies with physicians, and death certificate studies (the Netherlands and Belgium) were reviewed for the period 1947 to 2016.nnnFINDINGSnCurrently, euthanasia or physician-assisted suicide can be legally practiced in the Netherlands, Belgium, Luxembourg, Colombia, and Canada (Quebec since 2014, nationally as of June 2016). Physician-assisted suicide, excluding euthanasia, is legal in 5 US states (Oregon, Washington, Montana, Vermont, and California) and Switzerland. Public support for euthanasia and physician-assisted suicide in the United States has plateaued since the 1990s (range, 47%-69%). In Western Europe, an increasing and strong public support for euthanasia and physician-assisted suicide has been reported; in Central and Eastern Europe, support is decreasing. In the United States, less than 20% of physicians report having received requests for euthanasia or physician-assisted suicide, and 5% or less have complied. In Oregon and Washington state, less than 1% of licensed physicians write prescriptions for physician-assisted suicide per year. In the Netherlands and Belgium, about half or more of physicians reported ever having received a request; 60% of Dutch physicians have ever granted such requests. Between 0.3% to 4.6% of all deaths are reported as euthanasia or physician-assisted suicide in jurisdictions where they are legal. The frequency of these deaths increased after legalization. More than 70% of cases involved patients with cancer. Typical patients are older, white, and well-educated. Pain is mostly not reported as the primary motivation. A large portion of patients receiving physician-assisted suicide in Oregon and Washington reported being enrolled in hospice or palliative care, as did patients in Belgium. In no jurisdiction was there evidence that vulnerable patients have been receiving euthanasia or physician-assisted suicide at rates higher than those in the general population.nnnCONCLUSIONS AND RELEVANCEnEuthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices.

A Public Health Perspective on End of Life Care

CARE FOR those at the end of their lives is something that must concern all health professionals, not just those of us who nurse older people. And there is no doubt that every individual has some thoughts on how - and where - they would like to approach death. We see this need in ourselves, our relatives and our patients. But how far those hopes and wishes can be respected and achieved is another matter.

Descriptions of euthanasia as social representations: comparing the views of Finnish physicians and religious professionals

In many western societies health professionals play a powerful role in peoples experiences of dying. Religious professionals, such as pastors, are also confronted with the issues surrounding death and dying in their work. It is therefore reasonable to assume that the ways in which death-related topics, such as euthanasia, are constructed in a given culture are affected by the views of these professionals. This qualitative study addresses the ways in which Finnish physicians and religious professionals perceive and describe euthanasia and conceptualises these descriptions and views as social representations. Almost all the physicians interviewed saw that euthanasia does not fit the role of a physician and anchored it to different kinds of risks such as the slippery slope. Most of the religious and world-view professionals also rejected euthanasia. In this group, euthanasia was rejected on the basis of a religious moral code that forbids killing. Only one of the religious professionals - the freethinker with an atheist world-view - accepted euthanasia and described it as a personal choice, as did the one physician interviewed who accepted it. The article shows how the social representations of euthanasia are used to protect professional identities and to justify their expert knowledge of death and dying.

The public's viewpoint on the right to hastened death in Alberta, Canada: findings from a population survey study

A research study was conducted to determine public opinion in Alberta, a Canadian province, on the controversial topic of death hastening. Questions on the right to hastened death, end-of-life plans and end-of-life experiences were included in the Population Research Laboratorys annual 2010 health-care telephone survey, with 1203 adults providing results relatively representative of Albertans. Of all 1203, 72.6% said yes to the question: Should dying adults be able to request and get help from others to end their life early, in other words, this is a request for assisted suicide? Among all who provided an answer, 36.8% indicated yes, every competent adult should have this right and 40.6% indicated yes, but it should be allowed only in certain cases or situations. Over 50% of respondents in all but one socio-demographic population sub-group (Religious-other) were supportive of the right to hastened death. However, multinomial regression analysis revealed that the experiences of deciding to euthanise a pet/animal and developing or planning to develop an advance directive predicted support, while self-reported religiosity predicted non-support. Finding majority public support for death hastening suggests that legalisation could potentially occur in the future; but with this policy first requiring a careful consideration of the model of assisted suicide or euthanasia that best protects people who are highly vulnerable to despair and suffering near the end of life.

Euthanasia and Physician-Assisted Suicide—In Reply

ducted and elsewhere, as well as the comprehensive care that Remy and colleagues provide to families grieving after the death of their children. The study was not designed to test the effectiveness of intensive and comprehensive palliative care consultation for families of ICU patients. Instead, the goal was to learn whether family and patient outcomes might be improved by having structured, supportive conversations that focused on explaining the nature and prognosis of chronic critical illness compared with usual communication provided by intensivists. Palliative care clinicians are trained and frequently consulted to lead discussions of prognosis and goals of care. We asked palliative care clinicians rather than intensivists to conduct the conversations in the study to eliminate the confounder of baseline clinician communication skills. What does this study add to the science of communication interventions? The findings show that, beyond what is already provided by skilled ICU clinicians, supportive and informative discussions led by other skilled communicators do not by themselves improve the outcomes that were evaluated. As Martin points out, we cannot know from the findings whether this intervention would have any benefit in ICUs where the staff is less skilled or less available to meet with families. With regard to other factors that may have been associated with outcomes such as family anxiety or stress, we adjusted for the occurrence of patient death by time of family interview and for full formal palliative consultation; neither of these factors explained the lack of differences in the primary outcomes. We do not have data on palliative care or other interactions after hospital discharge or follow-up measurements beyond the 3-month interviews. The study was not intended to examine the effectiveness of comprehensive palliative care consultation for patients who are critically ill and their families. Its findings should not be interpreted to undermine the evidence showing the benefits of specialty palliative care and comprehensive communication interventions for this population.