Formée en France, je travaille en Belgique depuis 2015. Je suis médecin généraliste, diplômée en soins palliatifs après deux années de formation théorique et de stages. Avant 2015, j'ai travaillé en France en équipe mobile de soins palliatifs intra et extra hospitalière, ainsi qu'en unité de soins palliatifs.
Depuis l'Oregon Death with Dignity Act adopté en 1997, la dépénalisation de l'euthanasie aux Pays-Bas en 2001, puis en Belgique l'année suivante, de plus en plus de personnes demandent l'euthanasie ou en considèrent la possibilité.
AIMS AND OBJECTIVES: To explore how Flemish nurses working in hospitals and home care experience their involvement in the care of patients requesting euthanasia 15 years after the legalisation of euthanasia.
BACKGROUND: Euthanasia was legalised in Belgium in 2002. Despite prior research that charted the experiences of nurses in euthanasia care before and right after legalisation in Belgium, it remains unclear how Flemish nurses currently, 15 years after the legalisation, experience their involvement.
DESIGN: A grounded theory design, using semi-structured in-depth interviews.
METHODS: We interviewed 26 nurses working in hospitals or in home care, who had experience with caring for patients requesting euthanasia. Data were collected using a purposive sample and then a snowball sample. Data collection and data analysis were conducted simultaneously. Data were analysed by using the Qualitative Analysis Guide of Leuven. The study adhered to the COREQ guidelines.
RESULTS: Caring for a patient requesting euthanasia continues to be an intense experience characterized by ambivalence. The nature of euthanasia itself contributes to the intensity of this care process. The nurses described euthanasia as something unnatural and planned that generated many questions and doubts. Nevertheless, most interviewees stated that they were able to contribute to a dignified end of life and make a difference, giving them a profound feeling of professional fulfilment. However, when nurses were not able to contribute to good euthanasia care, they struggled with strong negative feelings and frustrations.
CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Although the results suggest some subtle shifts in nurses' experiences over time, they do not indicate perceptions of euthanasia as a normal practice by the nurses involved. Research on the perceptions of nurses who have strong negative experiences or conscientious objections is needed to further clarify nurses' ethical positions on euthanasia care.
AIMS: To explore the intentions of nurses to respond to requests for legal assisted dying.
BACKGROUND: As more Western nations legalise assisted-dying, requests for access will increase across clinical domains. Understanding the intentions of nurses to respond to such requests is important for the construction of relevant policy and practice guidelines.
DATA SOURCES: 45 Australian nurses from aged, palliative, intensive or cancer care settings surveyed in November 2018.
METHOD: Q-methodology studying nurses' evaluations of 49 possible responses to a request for a hastened death. Data consisted of rank-ordered statements analysed by factor analysis with varimax rotation.
FINDINGS: Four distinct types of intentions to respond to requests for assisted-dying: a) refer and support ; b) object to or deflect the request; c) engage and explore the request; or d) assess needs and provide information.
CONCLUSION: The findings underscore the complexity of intentionality in assisted dying nursing practice and differences from other forms of end-of-life care, particularly regarding patient advocacy and conscientious objection. This study enables further research to explore determinants of these intentions. It can also assist the development of professional guidance by linking policy and clinical intentions.
IMPACT: Identified a basic range of nurses' intentions to respond to requests for assisted dying, as there was no evidence at present. Developed a four-fold typology of intentions to respond with most nurses intending to engage in practices that support the requestor and sometimes the request itself. A minority would object to discussing the request. The relatively low level of advocacy within the intended responses selected also is distinctly different from other end-of-life care research findings. This research could assist nursing associations in jurisdictions transitioning to legal assisted-dying to develop guidance ways nurses can frame their responses to requests.
The Canadian province of Quebec enacted in 2014 a legislation that permitted medical assistance in dying (MAID) under specific conditions and the rest of Canada followed suit in June 2016. In this article, which is the second in a set of case series of requests for MAID in Canadian psychiatry, we present the cases of two patients who made a request for MAID to their treating psychiatrist in an outpatient clinic. While one is advanced in age and suffering from intense physical and psychic pain with little if any psychiatric comorbidity, the other is a young and medically healthy woman who nonetheless suffers from extensive psychiatric comorbidity. This article discusses both cases in light of recent scientific literature and case law that is slowly emerging in Canada, focusing on the concepts of the end of life and its legal definition as well as psychic suffering and its management in those wishing to receive physician-assisted dying. In our conclusion, we stress the need to clarify the definition of treatment resistance, the necessity to determine each physician's role when many are involved, as well as the importance of treating psychic pain holistically, which can sometimes require going beyond standard psychiatric care.
The number of elderly suffering from dementia and complex disabilities is gradually increasing in nursing homes, and they form a differentiated group that requires palliative care provided by practitioners in various disciplines from the time of their admission to improve the quality of their remaining lives. The purpose of this study was to explore an interdisciplinary care approach by nurses and related practitioners for the demented and complex-disabled elderly in nursing homes that focuses on palliative care based on an ethical point of view. A qualitative thematic analysis was conducted through in-depth interviews of 29 interdisciplinary practitioners working at 5 nursing homes. From them, 3 themes and 9 subthemes were extracted as the key results. First, practitioners set up cooperative care plans based on constantly tracking down clues to gradual functional deteriorations. Second, practitioners establish a cooperative committee to link residents and practitioners for responding to the subtle expressions of the elderly. Finally, practitioners maximize the opportunities for improving the quality of the elderly’s remaining lives. These results can be the basis for the first prototype in developing interdisciplinary practical guidelines for nursing home–specific palliative care and can provide new insights for the practical care concept of palliative care.
BACKGROUND: In the Netherlands, in 2002, euthanasia became a legitimate medical act, only allowed when the due care criteria and procedural requirements are met. Legally, an Advanced Euthanasia Directive (AED) can replace direct communication if a patient can no longer express his own wishes. In the past decade, an exponential number of persons with dementia (PWDs) share a euthanasia request with their physician. The impact this on physicians, and the consequent support needs, remained unknown. Our objective was to gain more insight into the experiences and needs of Dutch general practitioners and elderly care physicians when handling a euthanasia request from a person with dementia (PWD).
METHODS: We performed a qualitative interview study. Participants were recruited via purposive sampling. The interviews were transcribed verbatim, and analyzed using the conventional thematic content analysis.
RESULTS: Eleven general practitioners (GPs) and elderly care physicians with a variety of experience and different attitudes towards euthanasia for PWD were included. Euthanasia requests appeared to have a major impact on physicians. Difficulties they experienced were related to timing, workload, pressure from and expectations of relatives, society's negative view of dementia in combination with the 'right to die' view, the interpretation of the law and AEDs, ethical considerations, and communication with PWD and relatives. To deal with these difficulties, participants need support from colleagues and other professionals. Although elderly care physicians appreciated moral deliberation and support by chaplains, this was hardly mentioned by GPs.
CONCLUSIONS: Euthanasia requests in dementia seem to place an ethically and emotionally heavy burden on Dutch GPs and elderly care physicians. The awareness of, and access to, existing and new support mechanisms needs further exploration.
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’euthanasie des patients mineurs est autorisée en Belgique depuis 2014. Selon les critères de la loi, le mineur d’âge atteint d’une maladie incurable sévère et dans un état de souffrance physique inapaisable doit faire lui-même la demande d’euthanasie même si un consentement parental est requis. La loi belge ne prévoit pas de limite d’âge mais l’enfant qui demande l’euthanasie doit être capable de discernement. Le débat éthique de l’euthanasie des patients mineurs interroge les principes d’autonomie, de bienfaisance, de non malfaisance et de justice.
La sédation profonde et continue maintenue jusqu’au décès (SPCMJD) à la demande du patient bouscule les pratiques et mobilise les valeurs soignantes. Nous choisirons d’aborder le lien entre demande de mort anticipée et SPCMJD. Dès lors qu’elle est émise dans le contexte d’une détresse psychologique, comment la penser ? Dans ce contexte la caractérisation du syndrome de démoralisation au moment de la phase terminale nous paraît cliniquement pertinente.
CONTEXT: Studies have shown that palliative care involvement delivers a multitude of benefits to patients and caregivers. The existing palliative care workforce is inadequate to meet growing demand. Innovative strategies to triage inpatient consults are necessary.
OBJECTIVES: To describe the implementation of a new palliative care triage process and to demonstrate its impact on efficiency, teamwork, and patient care.
METHODS: A quasi-experimental study design, comparing clinical consult data from a 6-month period before and a 6-month period after implementation of the novel consult triage model.
RESULTS: Across the 2 study periods, consult demand increased by 44% while the physician staffing (full time equivalent [FTE]) decreased by 38%. Penetration rate per clinical FTE increased (from 1.9%-2.4%; P = .004). Monthly physician work relative value units (RVUs) per FTE increased from 909 to 1678. Physician encounters with hospitalized patients increased from 284 to 353, and total team visits increased from 596 to 891 (P < .001). Average time to consult decreased by 2.4 hours (P = .54).
CONCLUSION: An efficient and streamlined consult triage process had a positive impact on our palliative care team's ability to reach patients. We were able to generate more physician visits and RVUs despite a decrease in physician clinical time, and our penetration rate per physician clinical FTE improved. Our findings highlight the importance of thoughtful and appropriate triage, not to mention teamwork, in helping to augment patient access to palliative care.
Quebec’s Superior Court has ruled in favour of two plaintiffs who were denied medical assistance in dying because their conditions did not imminently threaten to end their lives.
ssisted dying laws in both Canada and Quebec stipulate that only patients facing “reasonably foreseeable” death may access medical assistance in dying. But this requirement contravenes Canada’s charter of rights and freedoms, ruled Justice Christine Baudouin. She gave the federal and provincial governments six months to amend their laws before those provisions are suspended. Both governments said that they would study the ruling before deciding whether to appeal.
[Début de l'article]
BACKGROUND: Notwithstanding fears of overly permissive approaches and related pleas to refuse euthanasia for psychological suffering, some Belgian hospitals have declared that such requests could be admissible. However, some of these hospitals have decided that such requests have to be managed and carried out outside their walls.
MAIN TEXT: Ghent University Hospital has developed a written policy regarding requests for euthanasia for psychological suffering coming from patients from outside the hospital. The protocol stipulates several due care criteria that go beyond the requirements of the Belgian Euthanasia Law. For instance, the legally required first and second consulted physicians should all be psychiatrists and be affiliated with a psychiatry department of a Flemish university hospital. Moreover, euthanasia for psychological suffering can only be performed if the advices of these consulted physicians are positive. Importantly, preliminary reflection by the multidisciplinary Hospital Ethics Committee was introduced to discuss every request for euthanasia for psychological suffering coming from outside the hospital.
CONCLUSION: In this way, the protocol supports psychiatrists faced with the complexities of assessing such requests, improves the quality of euthanasia practice by ensuring transparency and uniformity, and offers patients specialised support and guidance during their euthanasia procedure. Nevertheless, some concerns still remain (e.g. relating to possible unrealistic patient expectations and to the absence of aftercare for the bereaved or for patients whose requests have been refused).
This article analyzes suicidal behavior and how its inherent processes of death ideation can overlap with those seeking euthanasia. We present a literature review of three main events in suicide (suicidal ideation, suicide attempt, and suicide) in different populations and evaluate implications for health-care practice and risk assessment taking into account the context of euthanasia. We ponder upon the motives behind suicide and its link with wish to die requests to hasten death. We discuss the possibility of the reversal of a wish to die as well as a potential process of differentiating between individuals who would maintain their wish and benefit from termination of life and others who would later change their minds.
Medicine aims to relieve patient suffering and cure illness. To relieve suffering is the heart of what doctors do. However, respect for individual autonomy and self-determination are fundamental principles in Western medical ethics and decision-making, often expressed as a desire for control over the timing and manner of death. Patients who become demented often formulate advance euthanasia and assisted suicide directives. Dealing with such request is quite complex because of the specific medical and conflicting ethical questions they raise. Some specific medical and ethical issues arise regarding these substantive requirements when evaluating the euthanasia request of a person suffering from dementia. In jurisdictions that allow euthanasia, the most fundamental prerequisite for a person to make autonomous decisions is capacity. Whether anyone with moderate or severe dementia, and even some with mild dementia, could be deemed to be competent by these criteria is debatable, but during the course of their disease people with dementia sooner or later lose their capacity to make self-determined decisions.
BACKGROUND: In June 2016, the Government of Canada passed Bill C-14 decriminalizing medically assisted death. Increasing numbers of Canadians are accessing medical assistance in dying (MAiD) each year, but there is limited information about this population.
OBJECTIVE: To describe the characteristic outcomes of MAiD requests in a cohort of patients at an academic tertiary care center in Toronto, Ontario, Canada.
METHODS: A retrospective chart review of patients making a formal request for a MAiD eligibility assessment from July 16 to September 18. Data extracted included demographics, diagnosis, psychosocial characteristics, information relating to the MAiD request, and clinical outcome.
RESULTS: We received 107 formal requests for MAiD assessment. Ninety-seven patients were found eligible, of whom 80 received MAiD. Cancer was the primary diagnosis for 78% and median age was 74 years. The majority of patients (64%) cited "functional decline or inability to participate in meaningful activities" as the main factor motivating their request for MAiD. Half of patients who received MAiD (46%) described their request as consistent with a long-standing, philosophical view predating their illness. The 10-day reflection period was reduced for 39% of provisions due to impending loss of capacity. Our cohort was very similar demographically to those described both nationally and internationally.
CONCLUSION: Patients seeking MAiD at our institution were similar to those described in other jurisdictions where assisted dying is legal and represent a group for whom autonomy and independence is critical. We noted a very high rate of risk of loss of capacity, suggesting a need for both earlier assessments and regular monitoring.
This article addresses ethical issues in the conduct of ethnographic research with vulnerable study participants, such as individuals with cognitive impairment. Seven ethical issues emerged from this case study, in which a participant diagnosed with Alzheimer's disease wished to pursue euthanasia in Switzerland: (a) How to protect the participant's autonomy while ensuring his decision had not resulted from untreated depression or modifiable social factors; (b) How to interpret self-harm; (c) How to protect the research team members' "mandated reporter" status; (d) How to counteract the attractive qualities of pro-euthanasia videos depicting an easy end to personal suffering; (e) How to find a better alternative to the common practice of reporting self-harm cases to Adult Protective Services and then removing these cases from studies; (f) How to leverage a participant's trust to address these issues; and (g) Whether researchers should do anything further to help address unmet needs in similar situations.
The majority of Dutch physicians feel pressure when dealing with a request for euthanasia or physician-assisted suicide (EAS). This study aimed to explore the content of this pressure as experienced by general practitioners (GP). We conducted semistructured in-depth interviews with 15 Dutch GPs, focusing on actual cases. The interviews were transcribed and analysed with use of the framework method. Six categories of pressure GPs experienced in dealing with EAS requests were revealed: (1) emotional blackmail, (2) control and direction by others, (3) doubts about fulfilling the criteria, (4) counterpressure by patient's relatives, (5) time pressure around referred patients and (6) organisational pressure. We conclude that the pressure can be attributable to the patient-physician relationship and/or the relationship between the physician and the patient's relative(s), the inherent complexity of the decision itself and the circumstances under which the decision has to be made. To prevent physicians to cross their personal boundaries in dealing with EAS request all these different sources of pressure will have to be taken into account.
This case study illustrates the complex role that a physician's conscience can play in end-of-life care. We examine a case from Vermont in which a terminally ill patient requests aid-in-dying from her primary care physician under the state's "Patient Choice and Control at End of Life" Act (Act 39). The physician feels conflicted: she is opposed to prescribing death-hastening medication but does not want to abandon her patient. Much of the medical ethics literature on conscience focuses on whether health care professionals should be permitted to abstain from providing morally contested medical services. Our analysis highlights the interplay of conflicting values that inform the physician's engagement with aid-in-dying, demonstrating that the issue is often more nuanced than the question of whether or not a physician can (or should) opt out.
The increasing prevalence of euthanasia in Belgium has been linked to changing attitudes. Using National health survey data (N = 9651), we investigated Belgian adults’ intention to ask a physician for euthanasia or continuous deep sedation in the hypothetical scenario of a terminal illness and examined its connection to sociodemographic and health characteristics. Respectively, 38.3 and 25.8% could envisage asking for euthanasia and continuous deep sedation. Those with very bad to fair subjective health and with depression more likely had an intention to ask for euthanasia, which suggests need for attention in the evaluation of requests from specific patient groups.