Wim Distelmans

Development of palliative care and legalisation of euthanasia: antagonism or synergy?

Debates about euthanasia often polarise opinion, but Jan Bernheim and colleagues describe how in Belgium the two camps grew up side by side to mutual benefit

Palliative sedation: Why we should be more concerned about the risks that patients experience an uncomfortable death

Please cite this article in press as: Deschepper R et al. Palliative sedation: Why we should be more concerned about the risks that patients experie uncomfortable death. PAIN (2013), http://dx.doi.org/10.1016/j.pain.2013.04.038 Reginald Deschepper a,⇑, Steven Laureys , Said Hachimi Idrissi , Jan Poelaert , Johan Bilsen a Department of Public Health, Vrije Universiteit Brussel, Brussel 1090, Belgium Coma Science Group, Cyclotron Research Centre and Neurology Department, University and University Hospital of Liege, Liege 4000, Belgium Cerebral Resuscitation Research Group and the Centre of Neuroscience, Gent 9000, Belgium Department of Anesthesiology, Vrije Universiteit Brussel, Brussel 1090, Belgium

Role and Involvement of Life End Information Forum Physicians in Euthanasia and Other End-of-Life Care Decisions in Flanders, Belgium

OBJECTIVE To describe role and involvement of Life End Information Forum (LEIF) physicians in end-of-life care decisions and euthanasia in Flanders. STUDY DESIGN All 132 LEIF physicians in Belgium received a questionnaire inquiring about their activities in the past year, and their end-of-life care training and experience. PRINCIPAL FINDINGS Response rate was 75 percent. Most respondents followed substantive training in end-of-life care. In 1 year, LEIF physicians were contacted 612 times for consultations in end-of-life decisions, of which 355 concerned euthanasia requests eventually resulting in 221 euthanasia cases. LEIF physicians also gave information about various end-of-life issues (including palliative care) to patients and colleagues. CONCLUSIONS LEIF physicians provide a forum for information and advice for physicians and patients. A similar health service providing support to physicians for all end-of-life decisions could also be beneficial for countries without a euthanasia law.

Questions and Answers on the Belgian Model of Integral End-of-Life Care: Experiment? Prototype?

This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan Bernheim, independent from but together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors.

Nationwide survey to evaluate the decision-making process in euthanasia requests in Belgium: do specifically trained 2nd physicians improve quality of consultation?

BackgroundFollowing the 2002 enactment of the Belgian law on euthanasia, which requires the consultation of an independent second physician before proceeding with euthanasia, the Life End Information Forum (LEIF) was founded which provides specifically trained physicians who can act as mandatory consultants in euthanasia requests. This study assesses quality of consultations in Flanders and Brussels and compares these between LEIF and non-LEIF consultants.MethodsA questionnaire was sent in 2009 to a random sample of 3,006 physicians in Belgium from specialties likely involved in the care of dying patients. Several questions about the last euthanasia request of one of their patients were asked. As LEIF serves the Flemish speaking community (i.e. region of Flanders and the bilingual Brussels Capital Region) and no similar counterpart is present in Wallonia, analyses were limited to Flemish speaking physicians in Flanders and Brussels.ResultsResponse was 34%. Of the 244 physicians who indicated having received a euthanasia request seventy percent consulted a second physician in their last request; in 30% this was with a LEIF physician. Compared to non-LEIF physicians, LEIF physicians were more often not a colleague (69% vs 42%) and not a co-attending physician (89% vs 66%). They tended to more often discuss the request with the attending physician (100% vs 95%) and with the family (76% vs 69%), and also more frequently helped the attending physician with performing euthanasia (44% vs 24%). No significant differences were found in the extent to which they talked to the patient (96% vs 93%) and examined the patient file (94% vs 97%).ConclusionIn cases of explicit euthanasia requests in Belgium, the consultation procedure of another physician by the attending physician is not optimal and can be improved. Training and putting at disposal consultants through forums such as LEIF seems able to improve this situation. Adding stipulations in the law about the necessary competencies and tasks of consulting physicians may additionally incite improvement. Irrespective of whether euthanasia is a legal practice within a country, similar services may prove useful to also improve quality of consultations in various other difficult end-of-life decision-making situations.

Implementation of a service for physicians' consultation and information in euthanasia requests in Belgium

AIM To study the implementation of LEIF, the consultation service which provides access to specially trained physicians to act as the legally required second physician in requests for euthanasia in Flanders and Brussels, Belgium, the use of which has been to shown to be beneficial to the careful practice of euthanasia. METHOD A representative sample of 3006 Belgian physicians from the area where LEIF is active received a questionnaire investigating their attitude and practice regarding euthanasia, asking about their knowledge of LEIF, their attitude towards the service, their use of the service and their intentions regarding its future use. FINDINGS Seventy-eight per cent of physicians knew about the existence of the organization, 90% felt supported by the idea of being able to consult a LEIF physician and 90% intended to use LEIF in the future. Only 35% of those who had received a euthanasia request since LEIF became active had made use of LEIF. Awareness, use and intended use of LEIF were lower among specific groups of physicians (e.g. specialists). Positive attitudes towards consultation and training were positively associated with future use of LEIF. CONCLUSION Implementation can be considered successful but LEIF should continue promoting its services as widely as possible, with specific attention paid to specialists.

Consulting a Trained Physician When Considering a Request for Euthanasia: An Evaluation of the Process in Flanders and The Netherlands

In Belgium and the Netherlands, consultation of a second independent physician by the attending physician is mandatory in euthanasia cases. In both countries, specialized consultation services have been established to provide physicians trained for that purpose. This retrospective study describes and compares the quality of consultation of both services based on surveys of attending physicians and those providing the consultation (consultants). While Dutch consultants discussed certain subjects, for example, alternative curative or palliative treatment more often with the attending physician than Belgian consultants, both usually discussed those subjects considered necessary for a quality consultation and were independent from patient and attending physician. Over 90% of attending physicians in both countries evaluated the consultant’s knowledge of palliative care, patient’s disease, and judicial procedure, and their communication skills, as sufficient. Consultation with specialized consultation services seems to promote quality of euthanasia consultations.

The Bitter, Expensive Pill at the End of Life

The Bitter, Expensive Pill at the End of Life To the Editor With initial amazement we read the recent Viewpoint of Shankaran et al.1 The practice of “Big Pharma” to scam patients at one of the most vulnerable moments of their lives with excessive drug cost is far from dignified. Over the years, the practice of euthanasia and/or physician-assisted death has been confronted with fierce opposition. But even the most creative critics using different formats of the “slippery slope” argument would never have come up with the intolerable practices of pharmaceutical firms.2,3 In Belgium (as well has the Netherlands and Luxemburg), euthanasia has been legal since 2002 with strict due care conditions and has been extensively monitored and studied.4 Unique for Belgium is that the law was passed together with the law on patient’s rights and the law on palliative care—the latter with increased funding over time.5 Secobarbital has not been available in Belgium since 1999. Taking inflation into account, the current price in the public pharmacy would have been between

Requests for Euthanasia/Physician-Assisted Suicide on the Basis of Mental Suffering: Vulnerable Patients or Vulnerable Physicians?

15 and

Characteristics of referral to a multidisciplinary palliative home care team.

30 (1500 mg). As an alternative, phenobarbital, in comparable dose, is available for a price between