It is April 18th, 2020. I am writing this piece in New York City, the current world epicenter of the COVID-19 pandemic, listening to the most recent updates on the number of cases and deaths from COVID-19. In the city where I was born, educated, raised a family, live and made a career in Psychiatric Oncology at Memorial Sloan Kettering Cancer Center. In New York City alone, there are now at least 130,000 confirmed cases of COVID-19 and close to 14,000 deaths due to the virus. About 1,300 patients were admitted to the hospital here today, and 507 people died here of COVID-19 today. But this is a global pandemic affecting more than 185 countries, a global tragedy. 2.4 million COVID-19 cases reported worldwide, 165,000 deaths.
Introduction: Advance directives are legal documents which individuals draw up to declare their treatment preferences and to appoint well-informed proxies to safeguard patient autonomy in critical situations when that individual is temporarily or no longer able to communicate these preferences. On December 22, 2017, the Italian Parliament approved the first law on end of life (“Provisions for informed consent and advance directives” L.219/2017), after a heated public and political debate lasting almost twenty years.
Objective: The aim of this study was to investigate the awareness, knowledge, opinions and attitudes regarding Italian Law 219/2017 and advance directives among the Italian population 15 months after its entry into force.
Methods: A nationwide population-based survey was conducted by a certified public opinion survey company. A sample size of 2000 interviews was planned. A structured questionnaire was developed to investigate awareness, opinions and attitudes concerning the law by a multiprofessional research team. The agreed-on version was pretested on a sample of 70 selected participants.
Results: The sample included 2000 valid interviews; 70.1% of respondents declared they had heard about the law on informed consent and advance directives. Respondents were asked to express their overall opinion on the law’s utility and importance: 88% declared that the law was quite or very important and 76% had a positive attitude towards making/registering advance directives.
Conclusion: The principles of Italian Law 219/2017 are aligned with the ethical sentiment of the vast majority of the Italian population. It is crucial to stimulate discussion to increase knowledge and awareness in order to increase the number of advance directives.
Do the elderly have special obligations during a pandemic, that is, something more than the duty we all have for hand washing, social distancing, and so on? I believe the answer is, yes, and foremost among these is an obligation for parsimonious use of newly scarce and expensive health care resources.
In a recent paper, Charles Foster argued that the epistemic uncertainties surrounding prolonged disorders of consciousness (PDOC) make it impossible to prove that the withdrawal of life-sustaining treatment can be in a patient's best interests and, therefore, the presumption in favour of the maintenance of life cannot be rebutted. In the present response, I argue that, from a legal perspective, Foster has reached the wrong conclusion because he is asking the wrong question. According to the reasoning in two leading cases-Bland and James-the principle of respect for autonomy creates a persuasive presumption against treatment without consent. Therefore, it is the continuation of treatment that requires justification, rather than its withdrawal. This presumption also works as the tiebreaker determining that treatment should stop if there is no persuasive evidence that its continuation is in the best interests of the patient. The presumption in favour of the maintenance of life, on the other hand, should be understood as an evidential presumption on a factual issue that is assumed to be true if unchallenged. However, the uncertainties regarding PDOC actually give reasons for displacing this evidential presumption. Consequently, decision-makers will have to weigh up the pros and cons of treatment having the presumption against treatment without consent as the tiebreaker if the evidence is inconclusive. In conclusion, when the right question is asked, Foster's argument can be turned on its head and uncertainties surrounding PDOC weigh in to justify the interruption of treatment in the absence of compelling contrary evidence.
OPINION STATEMENT: National supportive care guidelines for patients with cancer include recognition of patients' spirituality and spiritual needs. Experts differ on how best to address this dimension to our patients' lives. Some suggest that patients' medical team should take on spiritual care, and others suggest referral to chaplains or collaboration with outside clergy. In our view, the patient's medical team ought to best acknowledge patient spirituality when so desired by the patient, but intervention in the case of serious spiritual crisis ought to be the responsibility of those with specific training in this realm. For some patients, "concordance" between the specific spiritual tradition of the patient and chaplain is necessary where for others, non-denominational, secular, or inter-faith chaplaincy services are welcome. The central role for physicians and nurses in this area, is listening, awareness, respect, and where necessary, referral.
OPINION STATEMENT: As palliative care (PC) continues its rapid growth, an emerging body of evidence is demonstrating that its approach of interdisciplinary supportive care benefits many patient populations, including in the oncology setting. As studies and data proliferate, however, questions persist about who, what, why, when, and how PC as well as the ideal time for a PC consult and length of involvement. When comparing outcomes from chemotherapy trials, it is important to consider the dosing regimens used in the various studies. In the same way, it is important to account for the "dose" of the PC interventions utilized across studies, and apples to apples comparisons are needed in order to draw accurate conclusions about PC's benefits. Studies which include a true interdisciplinary PC intervention consistently show improvements in patient quality of life, as well as cost savings, with further study needed for other outcomes. These benefits cannot be extrapolated to care which may be labeled "palliative care," but which does not meet the standard of true interdisciplinary PC. The ultimate question is: Does PC indeed improve outcomes?
The descriptive study was conducted to investigate the knowledge, opinions, behaviors of senior nursing students regarding euthanasia and factors in Islam influencing these. Almost all students (97.7%) knew about euthanasia. Their knowledge, opinions and behaviors were affected by their beliefs about death, religious beliefs and the idea of being subject to euthanasia themselves. Religion influenced whether they wanted euthanasia to be legalized or would carry it out secretly. Students who would be willing for their relatives to undergo euthanasia would not want to participate in this. Knowledge about the concept of euthanasia should be increased and the subject further investigated in many dimensions.
L’auteur Jacques Brotchi retrace, dans un dialogue avec sa petite-nièce, l’évolution de la notion d’euthanasie et ses implications morales en Belgique et ailleurs. Avec clarté et délicatesse, il explique dans quelles circonstances chacun peut bénéficier du droit de choisir sa n de vie et partir dans l’apaisement et la dignité.
The question of a physician's involvement in aid in dying (or "assisted suicide") is being debated across the country. This article adopts no one position because its authors hold contrasting views. It aims instead to articulate the strongest arguments in favor of aid in dying and the strongest arguments opposed. It also addresses relevant terminology and reviews the history of its legalization in the United States.
Critics of organ donation after circulatory death (DCD) argue that, even if donors are past the point of autoresuscitation, they have not satisfied the "irreversibility" requirement in the circulatory and respiratory criteria for determining death, since their circulation and respiration could be artificially restored. Thus, removing their vital organs violates the "dead-donor" rule. I defend DCD donation against this criticism. I argue that practical medical-ethical considerations, including respect for do-not-resuscitate orders, support interpreting "irreversibility" to mean permanent cessation of circulation and respiration. Assuming a consciousness-related formulation of human death, I then argue that the loss of circulation and respiration is significant, because it leads to the permanent loss of consciousness and thus to the death of the human person. The DNR request by an organ donor should thus be interpreted to mean "do not restore to consciousness." Finally, I respond to an objection that if "irreversibility" has a medical-ethical meaning, it would entail the absurd possibility that one of two individuals in the same physical state could be alive and the other dead-an implication that some think is inconsistent with understanding death as an objective biological state of the organism. I argue that advances in medical technology have created phenomena that challenge the assumption that human death can be understood in strictly biological terms. I argue that ethical and ontological considerations about our nature bear on the definition and determination of death and thus on the permissibility of DCD.
From the start, I followed the case of Jahi McMath with great interest. In December 2013, she clearly fulfilled the diagnostic criteria for brain death. As a neurologist with a special interest in chronic brain death, I was not surprised that, after she was flown to New Jersey, where she became statutorily resurrected and was treated as a comatose patient, Jahi's condition quickly improved. In 2014, her family reported that she sometimes responded to simple motor commands. I shared the general skepticism regarding these reports, assuming that the family was in denial and was misinterpreting spinal myoclonus (a rapid, involuntary twitch generated by the spinal cord) as volitional. The family had noticed that when Jahi's heart rate was above eighty beats per minute, she was more likely to respond, as though the heart rate reflected some sort of inner level of arousal. So they began to make video recordings. I have been privileged to be entrusted with copies of these recordings, forty-eight of which proved suitable for assessing alleged responsiveness. All have been certified by a forensic video expert as unaltered. The first thing that struck me was that the great majority of the alleged responses were not spinal myoclonus. In fact, they did not resemble any type of spontaneous, involuntary movement described in patients paralyzed from high spinal cord lesions.
Terminal sedation is a medically induced coma from which the patient does not recover. Professional guidelines for palliative care restrict its use to within a few days of death. The law relating to its use in Australia is governed by the law of homicide, assisted suicide and the law of trespass. In this article, I argue that the law in Australia does not justify the restrictions on its use imposed by the professional guidelines, and that, ethically and legally, it can be made available to patients with a terminal disease, those who are likely to suffer serious physical or existential pain by remaining conscious, and for those who refuse food and water. Its use should be regulated to ensure that those asking for it are competent to do so, and that they are suffering from a medical condition that makes life intolerable for them.
BACKGROUND: Multidrug resistant pathogens are a large-scale healthcare issue. In particular, children with life-limiting conditions have a significantly increased risk of multidrug resistant pathogen colonization. Official hygiene requirements recommend children, who are colonized with multidrug resistant pathogens, to be isolated. In the context of pediatric palliative care, such isolation adversely affects the aim of social participation. To overcome this challenge of conflicting interests on a pediatric palliative care inpatient unit, a hygiene concept for patients colonized with multidrug resistant pathogens, called PALLINI, was implemented.
AIM: The aim of this study was to identify the nurses' attitudes and opinions toward PALLINI.
METHODS: Nurses (N = 14) from the pediatric palliative care unit were queried in guideline-oriented interviews. Interviews were analyzed qualitatively by means of content analysis.
RESULTS: The following four categories were identified: (1) safety, (2) effort, (3) quality of care, and (4) participation. All categories demonstrated ambivalence by nursing staff regarding PALLINI. Ambivalence arose from guaranteeing infection control versus noncompliance by the families, additional workload for patients with multidrug resistant pathogens versus lack of resources, impaired relationship with the parents versus enabling better care for the child, as well as enabling some limited contact versus the larger goal of genuine social participation. Despite this, nurses reported the importance of arranging everyday-life for the patients so that they experience as much social participation as possible.
CONCLUSION: The implementation of a new hygiene concept is challenging. Despite positive reception of PALLINI from the nurses, ambivalence remained. Addressing these ambivalences may be critical to best implement the new hygiene concept.
The Op-Ed article in the New York Times (November 4th, 2016), “On Assisted Suicide, Going Beyond Do No Harm” by Haider Javed Warraich provides an articulate and timely plea for more widespread availability and application of physician-assisted dying, or “suicide”, as part of end-of-life (EOL) medical care. While this profound intervention should be considered by physicians and others as an option for those able to express their wishes at the EOL, it must be considered in the context of the ethical principles appropriate for all health care interventions and recognized for its limited role in the overall approach to compassionate care for terminally ill people.
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Avocat au Barreau de Bruxelles, Bernard Mouffe livre une réflexion sur le droit à la mort, qu'il s'agisse de suicide, d'avortement ou d'euthanasie. Il analyse ce qui rassemble ces trois sujets et ce qui les sous-tend.
Much of the public debate around the legalisation of assisted dying remains binary: yes or no. But this is a dangerous oversimplification. Assisted dying laws exist along a continuum, argue Katherine Sleeman and Iain Chalmers
The Australian state of Victoria has become the latest jurisdiction to legalise assisted dying, joining Belgium, Canada, Luxembourg, the Netherlands, and several US states. Although assisted dying remains illegal in the UK, there are signs that the country is inching towards legalisation. For example, in March 2019 the Royal College of Physicians adopted a position of neutrality, and the BMA and Royal College of General Practitioners have both decided to consult their members on whether their official positions should change from opposition.
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L’objectif de ce texte est d’exposer la vision d’un théologien catholique, et professeur émérite en communication et journalisme sur la question de l’accompagnement spirituel des personnes qui demandent une euthanasie.
L’auteur présente sa réflexion personnelle sur l’euthanasie en Belgique et sur son extension aux enfants. En Belgique, un patient adulte peut demander depuis 2002 et à certaines conditions une assistance médicale au décès dénommée euthanasie. Les personnes mineures peuvent faire une démarche similaire depuis 2014. L’euthanasie ne se résume pas à un acte létal. Elle est la conclusion d’un long processus d’accompagnement et d’écoute du malade. La voix du malade devient prépondérante : la loi a permis au malade de rester le sujet et l’acteur de sa vie, y compris quand celle-ci entre dans sa phase terminale. Elle ouvre un espace de discussion et d’information préalable pour permettre aux deux protagonistes, malade et médecin, de rechercher la piste la meilleure à suivre. En pratique, l’euthanasie est un acte qui est le résultat d’une concertation transparente entre le malade et son médecin partagée avec la famille et l’équipe soignante.