Marie-Claude Prémont

Comparing end-of-life practices in different policy contexts: a scoping review

Objectives End-of-life policy reforms are being debated in many countries. Research evidence is used to support different assumptions about the effects of public policies on end-of-life practices. It is however unclear whether reliable international practice comparisons can be conducted between different policy contexts. Our aim was to assess the feasibility of comparing similar end-of-life practices in different policy contexts. Methods This is a scoping review of empirical studies on medical end-of-life practices. We developed a descriptive classification of end-of-life practices that distinguishes practices according to their legal status. We focused on the intentional use of lethal drugs by physicians because of international variations in the legal status of this practice. Bibliographic database searches were supplemented by expert consultation and hand searching of reference lists. The sensitivity of the search strategy was tested using a set of 77 articles meeting our inclusion criteria. Two researchers extracted end-of-life practice definitions, study methods and available comparisons across policy contexts. Canadian decision-makers were involved to increase the policy relevance of the review. Results In sum, 329 empirical studies on the intentional use of lethal drugs by doctors were identified, including studies from 19 countries. The bibliographic search captured 98.7% of studies initially identified as meeting the inclusion criteria. Studies on the intentional use of lethal drugs were conducted in jurisdictions with permissive (62%) and restrictive policies (43%). The most common study objectives related to the frequency of end-of-life practices, determinants of practices, and doctors’ adherence to regulatory standards. Large variations in definitions and research methods were noted across studies. The use of a descriptive classification was useful to translate end-of-life practice definitions across countries. A few studies compared end-of-life practice in countries with different policies, using consistent research methods. We identified no comprehensive review of end-of-life practices across different policy contexts. Conclusions It is feasible to compare end-of-life practices in different policy contexts. A systematic review of international evidence is needed to inform public deliberations on end-of-life policies and practice.

International changes in end-of-life practices over time: a systematic review

BackgroundEnd-of-life policies are hotly debated in many countries, with international evidence frequently used to support or oppose legal reforms. Existing reviews are limited by their focus on specific practices or selected jurisdictions. The objective is to review international time trends in end-of-life practices.MethodsWe conducted a systematic review of empirical studies on medical end-of-life practices, including treatment withdrawal, the use of drugs for symptom management, and the intentional use of lethal drugs. A search strategy was conducted in MEDLINE, EMBASE, Web of Science, Sociological Abstracts, PAIS International, Worldwide Political Science Abstracts, International Bibliography of the Social Sciences and CINAHL. We included studies that described physicians’ actual practices and estimated annual frequency at the jurisdictional level. End-of-life practice frequencies were analyzed for variations over time, using logit regression.ResultsAmong 8183 references, 39 jurisdiction-wide surveys conducted between 1990 and 2010 were identified. Of those, 22 surveys used sufficiently similar research methods to allow further statistical analysis. Significant differences were found across surveys in the frequency of treatment withdrawal, use of opiates or sedatives and the intentional use of lethal drugs (X2 > 1000, p < 0.001 for all). Regression analyses showed increased use of opiates and sedatives over time (p < 0.001), which could reflect more intense symptom management at the end of life, or increase in these drugs to intentionally cause patients’ death.ConclusionThe use of opiates and sedatives appears to have significantly increased over time between 1990 and 2010. Better distinction between practices with different legal status is required to properly interpret the policy significance of these changes. Research on the effects of public policies should take a comprehensive look at trends in end-of-life practice patterns and their associations with policy changes.

Independent research needed to inform end-of-life policy choices

In their CMAJ editorial, Flegel and Fletcher[1][1] call for a national dialogue on end-of-life care, arguing that policy change should not be the result of a single court decision.[1][1] In Canada, different medical end-of-life practices, such as treatment withdrawal, use of medication justified by

Les municipalités québécoises et le développement économique par la fiscalité : back to the future?

L’annonce, en 2015, de la disparition des Conférences régionales des élus (CRÉ) et de la réduction du financement central des Centres locaux de développement (CLD) a créé une onde de choc. Pourtant, elle ne tombe pas des nues. La décision appartient à un cycle qui ramène en sourdine un cycle beaucoup plus ancien, en remontée de puissance depuis le début du XXI siècle : celui de la concurrence perlée entre municipalités locales pour leur développement économique. On observe effectivement le retour d’une époque où les territoires sont davantage laissés en pâture aux forces économiques, maintenant nettement plus mondialisées devant un État social en recul. Les organismes de concertation locale qui disparaissent à l’échelle de la région ou qui sont reconfigurés à l’échelle de la MRC, accordaient une attention particulière aux populations des territoires et à leur développement social et culturel autant qu’économique. Ils n’auront été qu’un simple interlude.

Law and Risk (review)

about the appropriate institutional allocation of authority to make judgments about the community’s “constitutional morality.” Waluchow argues the case that it is no offence to democracy or the Rule of Law to entrust final responsibility for protecting this morality to the courts, acknowledging the discipline of the heavy burden of rational justification cast upon them and their strong commitment to what Lord Mansfield characterized as the “common law working itself pure”. This discussion is careful, balanced and, in my view, convincing. The publisher advertises this monograph as “clearly written and accessible to an academic and general audience” and “of interest to those concerned about the role of unelected judges in a democracy.” The second statement is, happily, true; as for the first, I am less certain. One hopes that this monograph will, in the subsequent editions that it most surely deserves, further instantiate the virtues of “the living tree.”

La réingénierie québécoise version municipale

Les dernieres elections quebecoises ont porte au pouvoir l’equipe liberale dirigee par Jean Charest. Lors de son discours inaugural, le Premier ministre du Quebec a annonce la mise en place d’un vaste programme de reingenierie de l’appareil public quebecois, marque par une vision conservatrice du role des pouvoirs publics. Ce programme articule autour de six grands chantiers de reorganisation, s’eclaire a la lumiere de projets de loi deposes en juin 2004. Or, l’etude de trois projets de loi permet de noter que les instances municipales seront au premier rang des organismes publics mis a contribution. L’ensemble des reseaux techniques de services publics des municipalites, depuis l’eau, les ordures, les services de prevention des incendies jusqu’aux reseaux routiers et de transport en commun, pourront etre soumis a un regime de financement qui permettrait tant au gouvernement provincial que federal, d’imposer des conditions de partenariats avec public-prive. La diversification promise des sources de financement pour les instances locales du Quebec pourrait bien etre un cadeau empoisonne, tant pour les autorites locales que pour les populations desservies par les reseaux.