Policies and practices have been developed to operationalize assisted dying processes in Canada. This project utilized an environmental scan to determine the spectrum of assisted death reporting practices and medical certificate of death (MCD) completion procedures both nationally and internationally. Findings suggest medically assisted dying (MAiD) is represented on the MCD inconsistently nationally and internationally. Related factors include the specifics of local assisted death legislation and variations in death-reporting legislation, variation in terminology surrounding assisted death and designated oversight agency for assisted dying reporting.
Recently, the Portuguese Parliament discussed four proposals aimed at allowing some forms of medically assisted death. However, all of them were rejected by the majority. Therefore, doctors who in some way accelerate a patient's death risk being convicted of the crime of homicide. Portuguese law provides some legal mechanisms that can exempt a doctor from criminal liability, such as causes excluding the conduct's wrongfulness, and causes excluding the doctor's culpability. Other elements to take into consideration are a proper interpretation of homicide crimes, thereby excluding conducts without the intent to kill; the relevance of patient consent; and the rejection of medical futility. This article explains how a doctor may not be held criminally accountable for medically assisted death, even in restrictive jurisdictions such as the Portuguese one.
The article looks into the case involving Fabiano Antoniani, who, following a major road accident, was left tetraplegic. Marco Cappato drove him to a Swiss clinic where Mr. Antoniani took his own life by self-administration of lethal pentobarbital sodium. Cappato was put on trial, but the Italian Constitutional Court urged the Parliament to decriminalise assisted suicide in extremely serious cases. From a comparison with other European countries, approaches range from restrictive (banning both active euthanasia and assisted suicide), to entirely permissive. An intermediate approach only entails a ban on active euthanasia. It would be desirable to uniformise the diverse national statutes on a European level, which would make it possible for everyone to receive assistance towards ending their suffering, with limitations to incurable cases to be medically verified, and at the end of a path designed to ensure that patient freedom of choice is upheld at all time.
À l'heure où les lobbies et les médias veulent promouvoir le suicide assisté et l'euthanasie, le signal d'alarme est lancé par un ancien Franc-maçon... Serge Abad Gallardo, bien connu pour son témoignage sur la franc-maçonnerie, est aussi bénévole en aumônerie d'hôpital depuis six ans. Il s'alarme de la volonté des lobbies et des médias de promouvoir le suicide assisté et l'euthanasie active sous couvert d'humanité. Son expertise lui permet de constater que, depuis quarante ans, les loges militent pour un « droit à mourir » alors que cela est loin de répondre à une attente populaire : les malades demandent de l'attention plutôt qu'une piqûre létale.
Pourquoi cet acharnement à voler leur mort ? En rassemblant les cas d'Alphie, Anne Bert, frère Vincent, etc., cet ouvrage nous ouvre à l'environnement des soins palliatifs, à l'approche médicale de la souffrance, à la réalité des dérives eugénistes et au pouvoir du médecin traitant. Il nous donne les outils pour ne pas nous laisser illusionner par ce « droit à mourir » alors qu'à nos côtés, des personnes en fin de vie accueillent avec courage l'inconnu de leur mort, attendant de nous un accompagnement aimant.
Serge Abad Gallardo utilise son expertise afin de nous livrer un témoignage qui vise à montrer, d'une part, l'implication de la franc-maçonnerie dans les débats sur l'euthanasie et, d'autre part, quel point les patients ont avant tout besoin d'un accompagnement attentif et bienveillant.
OBJECTIVE: Switzerland is among the few countries worldwide where a request for assisted suicide (AS) can be granted on the basis of a primary psychiatric diagnosis. Psychiatrists play an increasingly important role in this regard, especially when the request for AS arises in the context of suffering caused by severe and persistent mental illness (SPMI). The objective of the survey was to assess general attitudes among psychiatrists in Switzerland regarding AS requests from patients with SPMI.
METHOD: In a cross-sectional survey of 1,311 German-speaking psychiatrists in Switzerland, participants were asked about their attitude to AS for patients with SPMI, based on three case vignettes of patients diagnosed with anorexia nervosa, treatment-refractory depression, or severe persistent schizophrenia.
RESULT: From a final sample of 457 psychiatrists (a response rate of 34.9%) whose mean age was 57.8 years, 48.6% of respondents did not support access to AS for persons diagnosed with SPMI, 21.2% were neutral, and 29.3% indicated some degree of support for access. In relation to the case vignettes, a slightly higher percentage of respondents supported the patient's wish to seek AS: 35.4% for those diagnosed with anorexia nervosa, 32.1% for those diagnosed with depression, and 31.4% for those diagnosed with schizophrenia.
SIGNIFICANCE OF RESULTS: Although a majority of the responding psychiatrists did not support AS for SPMI patients, about one-third would have supported the wishes of patients in the case vignettes. In light of the increasing number of psychiatric patients seeking AS and the continuing liberalization of AS practices, it is important to understand and take account of psychiatrists' perspectives.
Canada's legalization of Medical Assistance in Dying (MAiD) in 2016 has had important implications for nursing regulators. Evidence indicates that registered nurses perform key roles in ensuring high-quality care for patients receiving MAiD. Further, Canada is the first country to recognize nurse practitioners as MAiD assessors and providers. The purpose of this article is to analyze the documents created by Canadian nursing regulatory bodies to support registered nurse and nurse practitioner practice in the political context of MAiD. A search of Canadian provincial and territorial websites retrieved 17 documents that provided regulatory guidance for registered nurses and nurse practitioners related to MAiD. Responsibilities of registered nurses varied across all documents reviewed but included assisting in assessment of patient competency, providing information about MAiD to patients and families, coordinating the MAiD process, preparing equipment and intravenous access for medication delivery, coordinating and informing health care personnel related to the MAiD procedure, documenting nursing care provided, supporting patients and significant others, and providing post death care. Responsibilities of nurse practitioners were identified in relation to existing legislation. Safety concerns cited in these documents related to ensuring that nurses understood their boundaries in relation to counseling versus informing, administering versus aiding, ensuring safeguards were met, obtaining informed consent, and documenting. Guidance related to conscientious objection figured prominently across documents. These findings have important implications for system level support for the nursing role in MAiD including ongoing education and support for nurses' moral decision making.
BACKGROUND: In Switzerland, people can be granted access to assisted suicide (AS) on condition that the person whose wish is to die performs the fatal act, that he has his decisional capacity and that the assisting person's conduct is not selfishly motivated. No restrictions relating to the ground of suffering are mentioned in the act. Existential suffering as a reason for wanting to die, however, gives raise to controversial issues. Moreover, existential suffering lacks definition and no consensus exists on how to evaluate and manage it. This study explores the perspectives of care professionals and volunteers from a "right-to-die organization" on existential suffering as a motive for assisted suicide requests.
METHODS: A qualitative study based on face-to-face interviews was conducted with twenty-six participants: palliative care and primary care providers as well as EXIT right-to-die organization volunteers. Elements from the grounded theory approach were used.
RESULTS: The twenty-six participants described existential suffering in a multiplicity of individual ways. In total, sixty-three stories were recounted. Their representations were grouped into eight categories: physical decline and its consequences, loneliness, fear of the future, life is over, loss of social significance, loss of hope for a better future, being a financial burden and loss of pleasurable activities. According to all participants, suffering coming from the loss of self-identity was always linked to physical decline, as if one's image completely defined someone's identity. Society's perception of old people and vulnerable people were also often questioned. Another interesting point was that only four stories referring to a "pure" existential suffering were found. This suffering was related to a feeling that life has come to an end, without identification of any other related restriction or suffering.
CONCLUSIONS: Existential suffering is multifaceted. Legislators and right-to-die organisations have to address the question of what make a AS acceptable. The plurality of existential suffering implies the need of a very personalized care. A better understanding of what it is made of could provide a "toolbox" to people concerned by these requests, helping them to explore it in order to offer suffering people a wider range of alternatives.
Seven states have legalized physician-assisted death (PAD) for competent, terminally ill individuals; these criteria exclude persons with dementia (PWD). However, there is ethical and policy discussion around expanding access to PAD to people with Alzheimer disease (AD). Here, we present attitudes toward PAD of cognitively normal individuals enrolled in a clinical trial that required them to learn whether they have elevated amyloid-ß, a biomarker that increases risk for cognitive decline owing to AD.
OBJECTIVE: To examine how Canadian newspapers portrayed physicians' role and medical assistance in dying (MAiD).
DESIGN: Qualitative textual analysis.
SETTING: Online and print articles from Canadian French and English newspapers.
PARTICIPANTS: 813 newspaper articles published from 1972 to 2016.
RESULTS: Key Canadian events defined five eras. From 1972 to 1990, newspapers portrayed physician's MAiD role as a social issue by reporting supportive public opinion polls and revealing it was already occurring in secret. From 1991 to 1995, newspapers discussed legal aspects of physicians' MAiD role including Rodriguez' Supreme Court of Canada appeal and Federal government Bills. From 1996 to 2004, journalists discussed professional aspects of physicians' MAiD role and the growing split between palliative care and physicians who supported MAiD. They also reported on court cases against Canadian physicians, Dr Kevorkian and suffering patients who could not receive MAiD. From 2005 to 2013, newspapers described political aspects including the tabling of MAiD legislation to change physicians' role. Lastly, from 2014 to 2016, newspapers again portrayed legal aspects of physicians' role as the Supreme Court of Canada was anticipated to legalise MAiD and the Québec government passed its own legislation. Remarkably, newspapers kept attention to MAiD over 44 years before it became legal. Articles generally reflected Canadians' acceptance of MAiD and physicians were typically portrayed as opposing it, but not all did.
CONCLUSIONS: Newspaper portrayals of physicians' MAiD role discussed public opinion, politicians' activities and professional and legal aspects. Portrayals followed the issue-attention cycle through three of five stages: 1) preproblem, 2) alarmed discovery and euphoric enthusiasm and 3) realising the cost of significant progress.
The legalization of medical assistance in dying (MAID) in Canada has presented an opportunity for physicians, policy makers, and patients to rethink end-of-life care. This article reviews the key features of the Alberta MAID framework and puts it in the context of other provinces and their MAID programs. We also compared policies and MAID practices in different provinces/territories of Canada. In addition, we used the Alberta MAID database to provide the current state of patient demographics and access to MAID services in Alberta in 2017-2018. Significant differences were identified between provincial/territorial MAID program processes and practices. Alberta, Ontario, and Quebec have more comprehensive frameworks. Alberta has dedicated resources to the support of MAID. The median age of those who received MAID service in Alberta from July 2017 to April 2018 was 70 years; a higher proportion were males (55%) and the majority included patients with a cancer diagnosis (70%). Approximately 39 per cent of MAID events happened in a hospital setting, and 38 per cent occurred in patients' homes. We have presented some recommendations on MAID program development, implementation, and review based on Alberta's experience with MAID over the past two years.
The legislation Bill C-14 legalized medical assistance in dying (MAiD) in Canada. After thorough assessments of eligibility by two clinicians, Bill C-14 allows for both intravenous-assisted death by a clinician (euthanasia) and prescription of oral medication for self-administration (assisted suicide). Nevertheless, since inception in June 2016, intravenous euthanasia is the main form of delivery of assisted death in Canada. The reasons why oral MAiD is underutilized in Canada are multifactorial. Currently, there is no consensus on either the medications or the protocols for oral administration, nor a comprehensive understanding of the potential side effects and complications associated with different regimens. The quality of evidence for optimal MAiD medications is low, so any suggested recommendations can only be informed by the global but generally anecdotal experience. The challenges for implementing oral MAiD in Canada include a need to enhance clinician comfort in prescribing oral medications as an alternative to intravenous administration. The goals for ideal oral MAiD medications are 100% effectiveness and minimal side effects, while ensuring that the needed dose is both palatable and deliverable in a tolerable oral volume. The Netherlands has the most experience worldwide and barbiturates have emerged as the most common, efficacious, and tolerable agents by patients. Based on this global experience and the over-arching goals for oral MAiD, we recommend the use of a secobarbital suspension combined with antiemetic prophylaxis.
OBJECTIVE: The Canadian province of Quebec has recently legalized medical aid in dying (MAID) for competent patients who satisfy strictly defined criteria. The province is considering extending the practice to incompetent patients. We compared the attitudes of four groups of stakeholders toward extending MAID to incompetent patients with dementia.
METHODS: We conducted a province-wide postal survey in random samples of older adults, informal caregivers of persons with dementia, nurses, and physicians caring for patients with dementia. Clinical vignettes featuring a patient with Alzheimer's disease were used to measure the acceptability of extending MAID to incompetent patients with dementia. Vignettes varied according to the stage of the disease (advanced or terminal) and type of request (written or oral only). We used the generalized estimating equation (GEE) approach to compare attitudes across groups and vignettes.
RESULTS: Response rates ranged from 25% for physicians to 69% for informal caregivers. In all four groups, the proportion of respondents who felt it was acceptable to extend MAID to an incompetent patient with dementia was highest when the patient was at the terminal stage, showed signs of distress, and had written a MAID request prior to losing capacity. In those circumstances, this proportion ranged from 71% among physicians to 91% among informal caregivers.
CONCLUSION: We found high support in Quebec for extending the current MAID legislation to incompetent patients with dementia who have reached the terminal stage, appear to be suffering, and had requested MAID in writing while still competent.
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.
This is a secondary analysis of three qualitative studies about MAiD in which researchers asked about the differences between suicide and MAiD. In all, researchers interviewed 52 Canadians; 7 were people who had requested MAiD and had been found ineligible, 6 were MAiD providers and 39 were socially and economically marginalized. The overwhelming response was that MAiD is better than suicide in the context of suffering at the end of life. Whereas these people perceived suicide as uncertain, difficult, and something that was usually done alone and without support, they thought MAiD was certain, painless, and more socially acceptable.
La fin de vie, et plus particulièrement l'euthanasie et le suicide médicalement assisté font l'objet de débats éthiques qui touchent à la fois les domaines politique, médical et juridique. Les auteures livrent leur réflexion sur l'incertitude médicale face aux demandes de morts anticipées. Après avoir décrit l'aspect législatif français sur ces questions et leur méthodologie de recherche, les auteures analysent les modalités et les motifs des demandes d'euthanasie et de suicide médicalement assisté ainsi que les différentes niveaux d'interprétation de ces demandes (désir de mort / souffrance). pour terminer, elles montrent de quelle manière la demande de hâter sa propre mort engage les patients, leurs proches et les médecins dans une temporalité particulière.
Les nouvelles législations en matière de fin de vie que ce soit en France ou en Belgique placent les soignants en dehors de leurs repères habituels, dans ce que les auteurs nomment une expérience de la transgression. Ces derniers reviennent sur le vécu des équipes dans ce type de situations.
L’accompagnement médical de la vie finissante a évolué très fortement ces dernières décennies. Les décisions d’arrêts de traitements susceptibles de prolonger la vie sont devenues la norme des fins de vie en réanimation. Ailleurs la pratique de la sédation influence souvent le moment de la mort en raccourcissant la durée des agonies. L’intention du médecin de faire mourir son malade doit être reconnue et clairement assumée. Mais elle est secondaire par rapport à ce que souhaite le malade lui-même dans sa fin de vie. Quand celui-ci n’est plus capable de s’exprimer, les membres de sa famille ou ceux qu’il a désignés peuvent déterminer ce qu’aurait été sa volonté. Alors le médecin peut s’appuyer sur ces informations pour que le malade décède dans les meilleures conditions possibles correspondant à ses souhaits y compris un raccourcissement de son agonie. Radicalement autre est l’acte euthanasique réservé à ceux qui sont capables de demander une mort lucide et volontaire dans les conditions légales des pays qui l’ont rendu possible.
La présente étude expose le contexte d’origine de la loi relative à l’euthanasie et les circonstances dans lesquelles elle a été pensée et adoptée. Elle rend compte des principaux débats qui ont émaillé l’élaboration du texte de loi et des grands choix opérés. Ensuite, elle fait état des difficultés et controverses apparues sur le terrain de l’interprétation et du contrôle des conditions de la loi. Enfin, elle donne un aperçu des débats en cours et propositions de loi visant à étendre le champ d’application de la loi.