Although palliative care and legalised euthanasia are both based on the medical and ethical values of patient autonomy and caregiver beneficence and non-maleficence,1 they are often viewed as antagonistic causes. A popular perception, for instance, is that palliative care is the province of religiously motivated people and the advocacy of euthanasia that of agnostics or atheists.2 3 The European Association for Palliative Care has voiced concerns that legalising euthanasia would be the start of a slippery slope resulting in harm to vulnerable patients such as elderly and disabled people and that it would impede the development of palliative care by appearing as an alternative.4 Data from the Netherlands and Belgium, where euthanasia is legal, do not provide any evidence of a slippery slope.5 6 Here, we focus on the effect of the process of legalisation of euthanasia on palliative care and vice versa by reviewing the published historical, regulatory, and epidemiological evidence
Conclusions The increased use of continuous deep sedation for patients nearing death in the Netherlands and the limited use of palliative consultation suggests that this practice is increasingly considered as part of regular medical practice.
Rurik Löfmark, Tore Nilstun, Colleen Cartwright, Susanne Fische, Agnes van der Heide, Freddy Mortier, Michael Norup, Lorenzo Simonato and Bregje D Onwuteaka-Philipsen for the EURELD Consortium
The book strives for as complete and dispassionate a description of the situation as possible and covers in detail: the substantive law applicable to euthanasia, physician-assisted suicide, withholding and withdrawing treatment, use of pain relief in potentially lethal doses, terminal sedation, and termination of life without a request (in particular in the case of newborn babies); the process of legal development that has led to the current state of the law; the system of legal control and its operation in practice; and, the results of empirical research concerning actual medical practice.
Proponents for the legalization of physician assisted suicide (PAS ) argue that it has been legal in Oregon since 1997 and that it works well. They maintain that palliative and hospice care can co-exist comfortably with the option for PAS. My aim was to examine these claims, in two cities in the Northwest of America; Seattle where there is no legalized PAS and Portland where PAS is legal.
Physician assisted suicide has been legal for a decade in the US state of Oregon. But palliative care specialist David Jeffrey says there are grave questions about whether people are being helped to die, when treatment for depression could be a highly successful alternative. In this week's Scrubbing Up column Dr Jeffrey, who is based at the University of Edinburgh, says a patient should be free to end their life - but doctors should not be involved.
John Coggon The German National Ethics Council has recently published its Opinion on Self- Determination and Care at the End of Life. 1 The Opinion raises and attempts to resolve issues that are troubling many people in many jurisdictions. Perhaps unsurprisingly, given the well-rehearsed range of views on euthanasia, assisted-suicide, suicide, and care for the dying, the Council’s Opinion is neither extreme in its suppositions nor in its proposals. This may not satisfy campaigners and commentators who sit on the polar edges of the debate, but it represents a predictable compromise, and will satisfy medical practitioners and those who are increasingly concerned with the inadequacy of palliative care for the elderly, the dying, and the chronically sick.
The National Ethics Council has intensively discussed the issues involved in dealing responsibly with dying. It has perused a large volume of material, obtained expert opinions, consulted with doctors and other medical specialists, and held meetings in Augsburg and Münster at which it exposed itself to public debate. The outcome is enshrined in the Opinion now presented. Self-determination and care at the end of life continues the examination of the themes addressed in the Opinion The advance directive published in June 2005. The present analysis, in conjunction with the clarification of terminology here proposed, may facilitate interpretation of the recommendations set out in that Opinion.
There is evidence from outside the UK to show that physicians’ religious beliefs influence their decision making at the end of life. This UK study explores the belief system of consultants, nurse key workers & specialist registrars & their attitudes to decisions which commonly must be taken when caring for individuals who are dying. Results showed that consultants’ religion & belief systems differed from those of nurses & the population they served. Consultants & nurses had statistically significant differences in their attitudes to common end of life decisions with consultants more likely to continue hydration & not withdraw treatment. Nurses were more sympathetic to the idea of PAS for unbearable suffering. This study shows the variability in belief system and attitudes to end of life decision making both within and between clinical groups. The personal belief system of consultants was not shown to affect their overall attitudes to withdrawing life-sustaining treatment or PAS.
The GMC is consulting on new draft guidance, End of life treatment and care: Good practice in decision-making. The new guidance updates and builds on our existing publication Withholding and withdrawing life-prolonging treatments (2002) which clarified what we regarded as acceptable practice in this difficult area of end of life care. Since it was published, there have been significant changes in legislation, case law, public policy and the understanding of the effects of treatments, all of which affect the framework within which end of life care is provided. The GMC has also produced new guidance on Consent: patients and doctors making decisions together (2008) which sets out the broad principles of good decision-making which apply across the range of situations that doctors face, including end of life care. It was agreed that the Withholding and withdrawing guidance should be reviewed and updated to take account of these developments.
In the linked study (doi:10.1136/bmj.b2772), Van den Block and colleagues report a national mortality follow-back study of end of life care in Belgium conducted during 2005 and 2006. The findings are a valuable contribution to understanding the context of dying in Belgium. They detail the frequency of team based palliative care; involvement of generalists; use of intensive alleviation of symptoms, which can extend to palliative sedation (termed continuous deep sedation); and the incidence of euthanasia and physician assisted suicide. However, the authors’ interpretation of the data and the conclusions they reach raise questions. Their conclusion that life shortening decisions, including euthanasia and physician assisted suicide, are not related to a lower use of palliative care in Belgium and often occur within the context of multidisciplinary care, misrepresents the frequencies they report and is tangential to the main findings.
Terminally ill cancer patients near the end of life may experience intolerable suffering refractory to palliative treatment. Although sedation is considered to be an effective treatment when aggressive efforts fail to provide relief in terminally ill patients, it remains controversial. The aim of this study was to assess the need and effectiveness of sedation in dying patients with intractable symptoms, and the thoughts of relatives regarding sedation. Controlled sedation is successful in dying patients with untreatable symptoms, did not hasten death, and yielded satisfactory results for relatives. This study also points to the importance of palliative care and the experience of professionals skilled in both symptom control and end-of-life care.