1999

Legalized physician-assisted suicide in Oregon--the first year's experience.
Chin-AE; Hedberg-K; Higginson-GK; Fleming-DW
N-Engl-J-Med. 1999 Feb 18; 340(7): 577-83

BACKGROUND AND METHODS: On October 27, 1997, Oregon legalized physician-assisted suicide. We collected data on all terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. The data were obtained from physicians' reports, death certificates, and interviews with physicians. We compared persons who took lethal medications prescribed under the act with those who died from similar illnesses but did not receive prescriptions for lethal medications. RESULTS: Information on 23 persons who received prescriptions for lethal medications was reported to the Oregon Health Division; 15 died after taking the lethal medications, 6 died from underlying illnesses, and 2 were alive as of January 1, 1999. The median age of the 15 patients who died after taking lethal medications was 69 years; 8 were male, and all 15 were white. Thirteen of the 15 patients had cancer. The case patients and controls were similar with regard to sex, race, urban or rural residence, level of education, health insurance coverage, and hospice enrollment. No case patients or controls expressed concern about the financial impact of their illness. One case patient and 15 controls expressed concern about inadequate control of pain (P=0.10). The case patients were more likely than the controls to have never married (P=0.04) and were more likely to be concerned about loss of autonomy due to illness (P=0.01) and loss of control of bodily functions (P=0.02). At death, 21 percent of the case patients and 84 percent of the controls were completely disabled (P<0.001). CONCLUSIONS: During the first year of legalized physician-assisted suicide in Oregon, the decision to request and use a prescription for lethal medication was associated with concern about loss of autonomy or control of bodily functions, not with fear of intractable pain or concern about financial loss. In addition, we found that the choice of physician-assisted suicide was not associated with level of education of health insurance coverage.

1998

Seven deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia.
Kissane-DW; Street-A; Nitschke-P
Lancet. 1998 Oct 3; 352(9134): 1097-102

BACKGROUND: During the 9 months between July, 1996, and March, 1997, the provision of euthanasia for the terminally ill was legal in the Northern Territory of Australia. Seven patients made formal use of the Rights of the Terminally Ill (ROTI) Act; four died under the Act. We report their clinical details and the decision-making process required by the Act. METHODS: We taped in-depth interviews with the general practitioner who provided euthanasia. Further information was available from public texts created by patients, the media, and the coroner. FINDINGS: All seven patients had cancer, most at advanced stages. Three were socially isolated. Symptoms of depression were common. Having met criteria of the Act, some patients deferred their decision for a time before proceeding with euthanasia. Medical opinions about the terminal nature of illness differed. INTERPRETATION: Provision of opinions about the terminal nature of illness and the mental health of the patient, as required by the ROTI Act, created problematic gatekeeping roles for the doctors involved.

National Council for Hospice and Specialist Palliative Care Services. Voluntary euthanasia: the council's view.
Nurs-Ethics. 1998 Jul; 5(4): 371-4

Euthanasia and the terminally ill: can the civil killing of others be eroded?
Kelleher-MJ; Payne-A; Corcoran-P; Chambers-D
Crisis. 1998; 19(3): 116-8

The present paper assesses attitudes towards the ending of life among a sample of 100 terminally ill hospice patients. Such a sample best provides an insight into the demand for euthanasia in this most extreme of circumstances. Of the completed interviews (64), 43 patients were fully aware of the implications of their condition; 35 expressed a definite opinion regarding euthanasia, 22 of whom favored the individual's right to choose the timing of death. Only 6 of these 22 were fully competent at the time of the interview and were not suffering from any depressive disorder. The implications of these results point to the need to consider the prevalence of depression, anxiety, and related disorders among those who seek an end to life. A failure to do so is likely to affect legislation worldwide, and, in turn, civilization itself.

The double effect of pain medication: separating myth from reality
Anderson-S
J Palliat Med 1998; 1: 315-28

The principle of double effect is used to justify the administration of medication to relieve pain even though it may lead to the unintended, although foreseen, consequence of hastening death by causing respiratory depression. Although a review of the medical literature reveals that the risk of respiratory depression from opioid analgesic is more myth than fact and that there is little evidence that the use of medication to control pain hastens death, the belief in the double effect of pain medication remains widespread. Applying the principle of double effect to end-of-life issues perpetuates this myth and results in the undertreatment of physical suffering at the end of life. The concept of double effect of opioids also has been used in support of legalization of physician-assisted suicide and euthanasia


Beneficent voluntary active euthanasia: a challenge to professionals caring for terminally ill patients.
Begley-AM
Nurs-Ethics. 1998 Jul; 5(4): 294-306

Euthanasia has once again become headline news in the UK, with the announcement by Dr Michael Irwin, a former medical director of the United Nations, that he has helped at least 50 people to die, including two between February and July 1997. He has been quoted as saying that his 'conscience is clear' and that the time has come to confront the issue of euthanasia. For the purposes of this article, the term 'beneficient voluntary active euthanasia' (BVAE) will be used: beneficient from the prima facie principle of beneficience, to do good, and voluntary to indicate that this must be carried out at the request of a competent client. This implies adherence to another prima facie principle, that of respect for autonomy. Active implies that something is done or given with the intention of hastening death. The word euthanasia itself simply means 'good death'. This article examines the moral positions of two nurses and one junior doctor towards the subject of BVAE and an attempt is made to represent the main conflicting moral positions. The central arguments against BVAE and counterarguments are presented. The conclusion reached is that consenting adults should not be prevented from availing themselves of BVAE if another consenting adult (a medical doctor) is available and capable of carrying out their wishes. This being the case, it is suggested that BVAE should be available as an option in hospices and in the community. The aims of this article are: to generate debate among professionals; to present a three-way discussion that might be useful as a focus for educational purposes, particularly at undergraduate level; to challenge professionals to confront the issue of euthanasia; and to plead the case of those who request assistance in exercising autonomy by gaining control over their own deaths.



Terminal sedation
Lynn-J
N-Engl-J-Med. 1998 Apr 23; 338(17): 1230


Sedation and the smoking gun: Double effect on trial
Dunphy-K
Prog Palliative Care 1998; 6: 209-12


The dying thoracic patient.
Krishna-G; Raffin-TA
Chest-Surg-Clin-N-Am. 1998 Aug; 8(3): 723-39

Health care providers should understand that the practice of good medicine includes not only diagnosing and curing diseases, but also effectively communicating with patients and families and helping terminally ill patients die a peaceful and dignified death. Patients in America come from varied backgrounds, and it is important for physicians to consider cultural and religious issues. Physicians should combine their clinical judgment with objective outcome data to provide optimal care for patients. Informed consent should be obtained from patients after offering a detailed plan of care that would include appropriate interventions and the consequences of no intervention. The physician should then assist the patient in making a decision that would provide the best possible future for that individual. The four fundamental principles of biomedical ethics, namely beneficence, nonmaleficence, autonomy, and justice, should be considered when analyzing an ethical problem. Voluntary active euthanasia, which means performing a deliberate act (e.g., administering a lethal injection) to end a patient's life, should not be performed by a physician. Withholding and withdrawing basic and advanced life support constitutes passive euthanasia. Good communication with patients early in the clinical course whenever possible results in an ethically correct decision. A nonconfrontational, sympathetic, and compassionate approach to family members and legal surrogates facing the immediate death of their loved ones leads to the best possible outcome. It is the duty of the physician to assure the patient and the family that he or she will not abandon the patient. Effective communication is the key to solving almost all ethical dilemmas when caring for the dying thoracic patient.


Current events and bioethical concerns in physician-assisted death.
Berger-JT; Rosner-F; Bennett-AJ
Mt-Sinai-J-Med. 1998 Sep; 65(4): 257-64

In June 1997, the Supreme Court of the United States found that the Constitution does not guarantee a right to physician-assisted suicide, thereby allowing states the opportunity to variously prohibit or permit such practice. The Court's findings notwithstanding, physician-assisted death remains a topic of intense medical, legal and philosophical discussion. Principled discourse variously supports both an ethical prohibition against assisted death and an ethical obligation to help some patients achieve death. Both theoretical and practical concerns are raised by the practice of physician-assisted death. This essay reviews recent events and developments concerning assisted suicide and euthanasia. The discussion which follows was generated by the members of the Committee on Bioethical Issues of the Medical Society of the State of New York and builds upon a previous Committee report.


Sedation for intractable distress in the dying--a survey of experts.
Chater-S; Viola-R; Paterson-J; Jarvis-V
Palliat-Med. 1998 Jul; 12(4): 255-69

Terminal sedation is a phrase that has appeared in the palliative care literature in the last few years. There has not been a clear definition proposed for this term, nor has there been any agreement on the frequency with which the technique is used. A postal survey of 61 selected palliative care experts (59 physicians, two nurses) was carried out to examine their response to a proposed definition for 'terminal sedation', to estimate the frequency of this practice and the reasons for its use, to identify the drugs and dosages used, to determine the outcome, and to explore the decision-making process. Opinions on physician-assisted suicide and voluntary euthanasia were also sought. Eighty-seven per cent of the experts responded from eight countries, although predominantly from Canada and the United Kingdom. Forty per cent agreed unequivocally with the proposed definition, while 4% disagreed completely. Eighty-nine per cent agreed that 'terminal sedation' is sometimes necessary and 77% reported using it in the last 12 months--over half of these for up to four patients. Reasons for using this method included various physical and psychological symptoms. The most common drugs used were midazolam and methotrimeprazine. Decision making usually involved the patient or family, and varied with respect to the ease with which the decision was made. The use of sedation was perceived to be successful in 90 out of 100 patients recalled. Ninety per cent of respondents did not support legalization of euthanasia. In conclusion, sedating agents are used by palliative care experts as tools for the management of symptoms. The term 'terminal sedation' should be abandoned and replaced with the phrase 'sedation for intractable distress in the dying'. Further research into the management of intractable symptoms and suffering is warranted.


Autonomy and its implications for palliative care: a northern European perspective.
Farsides-CC
Palliat-Med. 1998 May; 12(3): 147-51

This paper explores the implications for palliative care practitioners of the pre-eminence of autonomy as an ethical principle in contemporary health care ethics. It is suggested that some of the consequences of respecting patient autonomy might be unacceptable to carers, particularly when they feel their own autonomy might be compromised or their ethical values threatened.


Assisted suicide, euthanasia, and the neurologist. The Ethics and Humanities Subcommittee of the American Academy of Neurology.
Neurology. 1998 Mar; 50(3): 596-8



Death by request: assisted suicide and the oncologist [editorial]
Faber-Langendoen-K
Cancer. 1998 Jan 1; 82(1): 35-41


What are the potential cost savings from legalizing physician-assisted suicide?
Emanuel-EJ; Battin-MP
N-Engl-J-Med. 1998 Jul 16; 339(3): 167-72



Physician resource use and willingness to participate in assisted suicide.
Sulmasy-DP; Linas-BP; Gold-KF; Schulman-KA
Arch-Intern-Med. 1998 May 11; 158(9): 974-8

OBJECTIVE: To explore the relationship between general internists' tendency to conserve medical resources and their willingness to participate in physician-assisted suicide (PAS). DESIGN AND PARTICIPANTS: Survey of a random sample of general internists in 6 urban areas of the United States. MEASUREMENTS: We assessed the physicians' use of medical resources by constructing a scale based on 6 hypothetical clinical scenarios in which respondents were given a choice between resource-intensive and resource-conserving options. We then presented a scenario of a competent terminally ill patient with breast cancer making stable and persistent requests for PAS. RESULTS: Sixty-seven (33%) of the 206 respondents indicated that they would participate in the suicide of the depicted patient. In a multivariate model, physicians who were more conservative with resources were 6.4 times more likely than their resource-intensive counterparts to prescribe the requested drugs (P = .02); minority physicians were less willing than whites to participate in PAS (odds ratio, 0.34; P = .03). Physicians' number of years in practice, location, sex, reported percentage of fee-for-service patients, and self-reported strength and direction of financial incentives in the respondents' practices were not associated with willingness to prescribe drugs for PAS. CONCLUSIONS: Most general internists, especially minority physicians, are personally reluctant to participate in PAS. While the characteristics of their practices do not affect PAS, physicians who tend to practice resource-conserving medicine are significantly more likely than their resource-intensive counterparts to provide a lethal prescription at the request of a terminally ill patient.

1997


Parting ways at the bridge--when our accompaniment can go no further [editorial]
Roy-DJ
J-Palliat-Care. 1997 Autumn; 13(3): 3-4


Dutch euthanasia revisited.
Fenigsen-R
Issues-Law-Med. 1997 Winter; 13(3): 301-11

The results of a follow-up study of euthanasia by the Dutch government, five years after the first study, were published on November 26, 1996. This article provides a detailed review of the two reports comparing and contrasting the statistics cited therein. The author notes that the "rules of careful conduct" proposed by the courts and by the Royal Dutch Society of Medicine were frequently disregarded. Special topics included for the first time in the second study were the notification and non-prosecution procedure, euthanasia of newborns and infants, and assisted suicide in psychiatric practice. The authors of the follow-up report state that it would be desirable to reduce the number of "terminations of life without patients' request," but this must be the common responsibility of the doctor and the patient. They suggest that the person who does not wish to have his life terminated should declare this clearly, in advance, verbally and in writing, preferably in the form of a living will. Involuntary euthanasia was rampant in 1990 and equally rampant in 1995. The author concludes that Dutch doctors who practice euthanasia are not on the slippery slope. From the very beginning, they have been at the bottom.


End of life decisions in mentally disabled people [editorial]
van-der-Maas-P
BMJ. 1997 Jul 12; 315(7100): 73


Physician-assisted suicide and euthanasia in the Netherlands. Lessons from the Dutch
Hendin-H; Rutenfrans-C; Zylicz-Z
JAMA. 1997 Jun 4; 277(21): 1720-2


The problem of physician-assisted suicide.
Bernat-JL
Semin-Neurol. 1997; 17(3): 271-9

With the increasing acceptance of the right of patients to refuse life-sustaining treatment, some have argued that terminally ill patients have a corollary right to physician-assisted suicide (PAS) on request. However, there are important moral and legal distinctions between patients' refusals of therapy and requests for certain actions. Physicians must stop life-sustaining therapy when that therapy has been validly refused by patients. But physicians have no similar duty to provide actions, such as assistance in suicide, simply because they have been requested by patients. In deciding how to respond to patients' requests, physicians should use their judgment about the medical appropriateness of the request. The morality of PAS is debatable but it remains illegal in most jurisdictions. Advocates of legalizing PAS should fully understand three issues: (1) that such legalization would have a negative effect on the practice of palliative care and on the physician-patient relationship; (2) that legalization of voluntary euthanasia will follow the legalization of PAS; and (3) that involuntary euthanasia inevitably follows the legalization of voluntary euthanasia, as has occurred in the Netherlands over the past 12 years. Rather than suffer the harms resulting from legalizing PAS, our society should maintain its illegality and make an expanded effort to improve physicians' training and abilities to provide palliative care.


Pain and the choice to hasten death in patients with painful metastatic cancer.
Sullivan-M; Rapp-S; Fitzgibbon-D; Chapman-CR
J-Palliat-Care. 1997 Autumn; 13(3): 18-28

Unrelieved pain has been cited as an important reason why cancer patients may seek to hasten their deaths. We interviewed 48 patients with painful metastatic cancer to ascertain their interest in various active and passive modes of hastening death. Ninety percent of these patients supported the general right of terminally ill patients to passive modes of hastening death and 80% supported the right to active modes such as assisted suicide and euthanasia. If they developed severe pain that could not be relieved, 80% would instruct their physician write a "do not attempt resuscitation" order, 40%-50% would want to receive suicide information or a lethal prescription from their physician, and 34% would request a lethal injection from their physician. Current pain and depression levels were not associated with interest in hastening death, but current somatic symptom burden was significantly associated with this interest.


The Supreme Court and physician-assisted suicide--rejecting assisted suicide but embracing euthanasia
Orentlicher-D
N-Engl-J-Med. 1997 Oct 23; 337(17): 1236-9


Dying cancer patients: choices at the end of life.
Severson-KT
J-Pain-Symptom-Manage. 1997 Aug; 14(2): 94-8

Physician-assisted suicide and euthanasia have recently received considerable attention in the literature and in the courts. Surveys have been conducted assessing physicians' attitudes toward euthanasia and physician-assisted suicide. Five patients were followed and counseled in a cancer support group from time of diagnosis of their malignancies until death. These case reports demonstrate the need for further studies to include interviews of dying patients. Review of these cases indicates that factors in addition to pain management and the treatment of depression, such as care by family members, support groups, and spiritual concerns, can influence patients not to act on their previous requests for euthanasia or physician-assisted suicide.


BMA opposes legalisation of euthanasia
Beecham-L
BMJ. 1997 Jul 12; 315(7100): 80


Psychiatry and assisted suicide in the United States [editorial]
Ganzini-L; Lee-MA
N-Engl-J-Med. 1997 Jun 19; 336(25): 1824-6


Assisted suicide for HIV patients
Chochinov-HM; Wilson-KG
Am-J-Psychiatry. 1997 Feb; 154(2): 294-5


Competent care for the dying instead of physician-assisted suicide [editorial]
Foley-KM
N-Engl-J-Med. 1997 Jan 2; 336(1): 54-8


Improving palliative care
Meier-DE; Morrison-RS; Cassel-CK
Ann-Intern-Med. 1997 Aug 1; 127(3): 225-30

Although most deaths in the United States occur in hospitals, data suggest that hospitals and physicians are not equipped to handle the medical and psychosocial problems of dying patients. In this article, we review the barriers to achieving a peaceful death, including inadequate medical professional education on palliative care, and public and professional uncertainty about the difference between foregoing life-sustaining treatment and active euthanasia, and health professionals' difficulty recognizing when patients are dying and the associated sense that death is a professional failure. Other barriers include fiscal constraints on the length of stay, the number of nurses available to care for dying patients, legal and regulatory constraints on obtaining opioid prescriptions, and a segregated system of hospice care that requires patients to be separated from familiar health care providers and settings in order to receive palliative care at the end of life. Identifying the opportunities that can improve the delivery of palliative care at the end of life is the first step toward developing corrective approaches. Strategies that enhance these opportunities are proposed.

1996


The legalization of physician-assisted suicide
Orentlicher-D
N-Engl-J-Med. 1996 Aug 29; 335(9): 663-7


On the ethics of euthanasia discourse [editorial]
Roy-DJ
J-Palliat-Care. 1996 Winter; 12(4): 3-5


Euthanasia in the Netherlands--good news or bad? [editorial]
Angell-M
N-Engl-J-Med. 1996 Nov 28; 335(22): 1676-8


Assisted suicide and euthanasia: what about the clinical issues?
Kelly-BJ; Varghese-FT
Aust-N-Z-J-Psychiatry. 1996 Feb; 30(1): 3-8

This paper aims to address the clinical issues involved in a patient's request for assisted suicide. The psychiatric and broader psychosocial issues for the dying patient, their family and their treating doctor have been largely unaddressed in the debate concerning euthanasia to date. A range of the clinical issues that need to be incorporated in the ethical and legal considerations are reviewed. The reasons for a patient seeking suicide as a treatment are complex and go beyond questions of a patient's right to die. The request for euthanasia needs to be seen in the context of the patient's circumstances, including relationships with and attitudes of carers and health professionals, along with patterns of psychiatric disorder and psychiatric symptoms in the medically ill. The clinical issues involve not only the diagnosis or management of psychiatric disorder but also the acknowledgment of the factors influencing an individual's adjustment to the threat of illness and death. The dynamics of family interactions and doctor-patient relationships in this setting are factors that may impinge upon a request for assistance to die. These factors may be more important than the severity of a person's illness or their quality of life, and are less likely to be recognised and addressed in situations of professional isolation. There are critical issues facing psychiatry in new legislative developments.


Patients' views about physician participation in assisted suicide and euthanasia.
Graber-MA; Levy-BI; Weir-RF; Oppliger-RA
J-Gen-Intern-Med. 1996 Feb; 11(2): 71-6

OBJECTIVE:To elucidate the effect of physician participation in physician-assisted suicide and euthanasia on the physician-patient relationship. DESIGN: A questionnaire administered to 228 adult patients. SETTING: A university-based family practice training program. PATIENTS/PARTICIPANTS: We approached 230 individuals of at least 19 years of age who were patients in the study practice. These individuals were selected on the basis of age and gender to ensure a heterogeneous study population. Of these, 228 agreed to participate and completed the questionnaire. RESULTS: The majority of subjects felt that a physician who assists with suicide or performs euthanasia is capable of being a caring person (91% and 88%, respectively) and would still be able to offer emotional support to surviving family members (85% and 70%, respectively). Most also felt that a physician assisting in suicide or euthanasia would be as trustworthy as a nonparticipating physician to care for critically ill patients (90.5% and 84.6%, respectively). Five percent "likely would not" continue to see their physician if it was known that he or she assisted in suicide and 7.8% "likely would not" continue seeing their physician if it was known that this physician performed euthanasia. No individuals stated that they "definitely would not" continue seeing their doctor under either circumstance. Individuals who supported the ideas of physician-assisted suicide and euthanasia were more likely to think that a physician who assisted with suicide and euthanasia could perform well in the tasks noted above and would be more likely to continue seeing such a physician (p = .001). CONCLUSION: Participating in physician-assisted suicide and euthanasia does not markedly adversely affect the physician-patient relationship.


Major depression and refusal of life-sustaining medical treatment in the elderly
Hooper-SC; Vaughan-KJ; Tennant-CC; Perz-JM
Med-J-Aust. 1996 Oct 21; 165(8): 416-9

OBJECTIVE: To examine the effect of improvement or recovery from major depression in elderly patients on their desire for life-sustaining treatments. DESIGN: Prospective case survey. SETTING: Psychogeriatric Service of Hornsby Ku-ring-gai Hospital & Community Health Services and Ryde Hospital & Community Health Services (a community-based service serving an urban population with over 29,000 elderly people). SUBJECTS: All patients referred with major depression (diagnosed by DSM-IV criteria) and no significant cognitive impairment between October 1994 and January 1995. OUTCOME MEASURES: Number of life-sustaining treatments desired before and after treatment of depression in two hypothetical acute life-threatening illnesses (one with a good and the other with an uncertain prognosis), and intensity of depression on the Geriatric Depression Scale (GDS). RESULTS: 22 subjects completed both stages of the study. Initial depression was severe in five, moderate in 16 and mild in one. GDS scores decreased in 18 subjects after treatment. Mean number of life-sustaining treatments desired by these patients increased significantly from 4.0 to 6.1 (out of seven possible treatments) in the "good prognosis" illness and from 6.4 to to 9.6 (out of 14) overall. The increase in the "uncertain prognosis" illness (2.3 to 3.4) was not significant. CONCLUSIONS: Moderate or severe major depression in the elderly is associated with a high degree of refusal of life-sustaining treatments. Treatment of the depression leads to increased acceptance of these treatments, particularly if prognosis is good.


Depression, decisions and the desire to die [editorial]
Ryan-CJ
Med-J-Aust. 1996 Oct 21; 165(8): 411

1995

Professional negligence in the management of cancer pain. A case for urgent reforms [editorial]
Cherny-NI; Catane-R
Cancer. 1995 Dec 1; 76(11): 2181-5


Euthanasia, nursing and care of the dying: rethinking Kuhse and Singer.
Aranda-S; O'Conner-M
Aust-Nurs-J. 1995 Aug; 3(2): 18-21


Against medical killing [editorial]
Ernst-C
Support-Care-Cancer. 1995 Jan; 3(1): 3-4


The euthanasia debate: attitudes, practices and psychiatric considerations
Chochinov-HM; Wilson-KG
Can-J-Psychiatry. 1995 Dec; 40(10): 593-602

OBJECTIVE: To review the current status of the euthanasia debate by examining public and physician attitudes towards euthanasia, the practice of euthanasia in the Netherlands, recent developments in Canada and other countries, psychosocial considerations related to the desire for death in terminally ill patients, and the roles that psychiatrists may be asked to play in the event of legislative reform involving discriminalization. METHODS: A literature review was conducted focusing on recent surveys regarding physician and patient attitudes towards euthanasia, the role of psychiatrists and empirical data pertaining to the mental state of patients who request physician-hastened death. RESULTS: Psychiatric morbidity among patients requesting physician-hastened death is considerable. CONCLUSION: As a special case of suicide, euthanasia and physician-assisted suicide are of particular relevance to mental health professionals.


Dilemmas of life and death: Part one
Walton
J-R-Soc-Med. 1995 Jun; 88(6): 311-5


Dilemmas of life and death: Part two
Walton
J-R-Soc-Med. 1995 Jul; 88(7): 372-6


Desire for death in the terminally ill.
Chochinov-HM; Wilson-KG; Enns-M; Mowchun-N; Lander-S; Levitt-M; Clinch-JJ
Am-J-Psychiatry. 1995 Aug; 152(8): 1185-91

OBJECTIVE: Euthanasia and physician-assisted suicide have become prominent medical and social issues. This study investigated the prevalence of the desire for death in terminally ill patients, the stability of this desire over time, and its association with psychiatric disorders. METHOD: Two hundred terminally ill inpatients were given semistructured interviews that assessed their desire for death and evaluated them for major and minor depressive episodes according to the Research Diagnostic Criteria. Each patient also completed a short form of the Beck Depression Inventory and provided ratings of pain and social support. When possible, patients who expressed a desire for death received a follow-up interview after a 2-week interval. RESULTS: Although occasional wishes that death would come soon were common (reported by 44.5% of the patients), only 17 (8.5%) of these individuals acknowledged a serious and pervasive desire to die. The desire for death was correlated with ratings of pain and low family support but most significantly with measures of depression. The prevalence of diagnosed depressive syndromes was 58.8% among patients with a desire to die and 7.7% among patients without such a desire. Follow-up interviews were conducted with six patients; in four cases, the desire to die had decreased during the 2-week interval. CONCLUSIONS: The desire for death in terminally ill patients is closely associated with clinical depression--a potentially treatable condition--and can also decrease over time. Informed debate about euthanasia should recognize the importance of psychiatric considerations, as well as the inherent transience of many patients' expressed desire to die.



Misconceptions and controversies regarding the use of opioids in cancer pain.
Foley-KM
Anticancer-Drugs. 1995 Apr; 6 Suppl 3: 4-13

The WHO has created a Cancer Pain Relief Programme and developed guidelines for the treatment of cancer pain. Implementation of the analgesic guidelines, assurance of drug availability (specifically opioids), education of healthcare professionals, and designating cancer pain as a priority for all national cancer control programmes are the major goals. Recent studies of medical students, physicians, nurses and state medical boards demonstrate a significant lack of knowledge with regard to the theoretical and practical understanding of the use of analgesic drugs, particularly opioids, in the management of cancer pain. Communication between physicians and patients about pain symptoms has also been shown to be problematic. Limited availability of opioids, their excessive regulation, and the lack of use of alternatives to systemic analgesics also prevent adequate management. Although analgesic drug therapy is the mainstay of treatment, opioid use remains a controversial issue. Some of the controversies include their role in the management of neuropathic pain, which has been suggested to be 'opioid-resistant', as well as the choice of opioid drug. A third controversy is the route of administration. The impetus for the development of novel routes has come from the goals of maximising analgesia, minimising side effects, and providing convenient dosing schedules for patients who require parenteral administration. Other important controversial issues are the development of tolerance and the relationship of pain management to patient requests for physician-assisted suicide and euthanasia.

1994


Regarding euthanasia
Roy-DJ, Rapin C-H
Eur J Palliat Care 1994; 1:57-9


Prevalence of depression in the terminally ill: effects of diagnostic criteria and symptom threshold judgments.
Chochinov-HM; Wilson-KG; Enns-M; Lander-S
Am-J-Psychiatry. 1994 Apr; 151(4): 537-40

OBJECTIVE: Two issues that may influence the diagnosis of depression in the medically ill are 1) the severity with which symptoms must be expressed before they are considered clinically significant and 2) how to deal with somatic symptoms that may be caused by medical illness. This study used different approaches to case identification to examine prevalence rates for major and minor depression in a group of terminally ill cancer patients. METHODS: Semistructured diagnostic interviews were conducted with 130 patients receiving palliative care. Diagnoses according to the Research Diagnostic Criteria (RDC) were compared with diagnoses according to Endicott's revised criteria (which involve replacing somatic symptoms with non-somatic alternatives) when either a low-severity or a high-severity threshold for classifying RDC criterion A symptoms was used. RESULTS: A low-threshold (less stringent) diagnostic approach greatly increased the overall prevalence of major and minor depressive episodes with both the RDC and the Endicott criteria. With high thresholds, the RDC and the Endicott criteria were equivalent, whereas with low thresholds the Endicott substitutions identified fewer cases of major (but not minor) depression. CONCLUSIONS: Small differences between investigators in the applications of symptom-severity thresholds can result in large differences in prevalence rates for depression. However, the inclusions of somatic symptoms in the diagnostic criteria inflates the rates of diagnosis only when these symptoms are used in conjunction with a low-threshold approach.



Depression and suicide in patients with cancer.
Massie-MJ; Gagnon-P; Holland-JC
J-Pain-Symptom-Manage. 1994 Jul; 9(5): 325-40

Depression is a prevalent psychiatric syndrome in the cancer population. We review the spectrum of conditions in which depressive features are present, from normal responses to crises in cancer to depression secondary to organic causes. The different modalities of treatment, including pharmacologic, psychotherapeutic and social interventions, are described. Specific guidelines for the management of the suicidal cancer patient are given and physician-assisted death is discussed.


The effect of depression treatment on elderly patients' preferences for life-sustaining medical therapy
Ganzini-L; Lee-MA; Heintz-RT; Bloom-JD; Fenn-DS
Am-J-Psychiatry. 1994 Nov; 151(11): 1631-6

OBJECTIVE: This study was undertaken 1) to test the hypothesis that remission of depression results in an increase in desire for life-sustaining medical therapy and 2) to characterize patients whose desire for life-sustaining treatment increases substantially following depression therapy. METHOD: Elderly patients, suffering from major depression, were interviewed on admission to a psychiatric inpatient unit and at discharge about their desire for specific medical therapies in their current state of health and in two hypothetical scenarios of medical illness. A psychiatrist rated the impact of depressive thinking on the subject's response to these questions. Forty-three subjects completed the study, and 24 were in remission from depression at the time of discharge. RESULTS: In the majority of patients, remission of depression did not result in an increase in desire for life-sustaining medical therapy. However, a clinically evident increase in desire for life-sustaining medical therapies followed treatment of depression in subjects (N = 11 [26%]) who had been initially rated as more severely depressed, more hopeless, and more likely to overestimate the risks and to underestimate the benefits of treatment. CONCLUSIONS: In major depression of mild to moderate severity, a patient's desire to forgo life-sustaining medical treatment is unlikely to be altered by depression treatment. On the other hand, severely depressed patients, particularly those who are hopeless, overestimate the risks of treatment, or underestimate the benefits of treatment, should be encouraged to defer advance treatment directives. In these patients decisions about life-sustaining therapy should be discouraged until after treatment of the depression.


Death by prescription. The Oregon initiative.
Annas-GJ
N-Engl-J-Med. 1994 Nov 3; 331(18): 1240-3


When terminally ill patients request death: assisted suicide before Canadian courts.
Dickens-BM
J-Palliat-Care. 1994 Summer; 10(2): 52-6


The economics of dying. The illusion of cost savings at the end of life
Emanuel-EJ; Emanuel-LL
N-Engl-J-Med. 1994 Feb 24; 330(8): 540-4


Euthanasia--definition, dangers and alternatives.
Saunders-C
Ann-Acad-Med-Singapore. 1994 Mar; 23(2): 300-3

There is as yet (1992) no law specifically allowing euthanasia, the active intervention to end a patient's life. The discussion has so far been restricted to such action as taking place at a patient's request, but evidence from the Netherlands appears to show that the move to involuntary euthanasia is a real danger. Palliative medicine offers appropriate treatment for relief and support where limits are set on interventions that would no longer be in a patient's best interests. It is possible to relieve distress by using the increasing knowledge in this field. It is important to distinguish this from euthanasia and the term "passive euthanasia" is confusing and unfortunate. Those with extensive experience in the treatment of advanced cancer have much to share with practitioners in other specialties, not least in the possible achievements of both patient and family at the end of life. Society has the responsibility for including them in its concern to the end of life and for supporting those who find it difficult to believe in any meaning in their existence.


Euthanasia and the care of cancer patients.
Patterson-WB; Emanuel-EJ
J-Clin-Oncol. 1994 Jul; 12(7): 1516-21


The history of euthanasia debates in the United States and Britain.
Emanuel-EJ
Ann-Intern-Med. 1994 Nov 15; 121(10): 793-802

Debates about the ethics of euthanasia and physician-assisted suicide date from ancient Greece and Rome. After the development of ether, physicians began advocating the use of anesthetics to relieve the pains of death. In 1870, Samuel Williams first proposed using anesthetics and morphine to intentionally end a patient's life. Over the next 35 years, debates about the ethics of euthanasia raged in the United States and Britain, culminating in 1906 in an Ohio bill to legalize euthanasia, a bill that was ultimately defeated. The arguments propounded for and against euthanasia in the 19th century are identical to contemporary arguments. Such similarities suggest four conclusions: Public interest in euthanasia 1) is not linked with advances in biomedical technology; 2) it flourishes in times of economic recession, in which individualism and social Darwinism are invoked to justify public policy; 3) it arises when physician authority over medical decision making is challenged; and 4) it occurs when terminating life-sustaining medical interventions become standard medical practice and interest develops in extending such practices to include euthanasia.


The House of Lords on issues of life and death.
Walton-J
J-R-Coll-Physicians-Lond. 1994 May-Jun; 28(3): 235-6



Their lordships on euthanasia [editorial]
Lancet. 1994 Feb 19; 343(8895): 430-1


Statement on euthanasia and physician-assisted suicide.
Moulin-DE; Latimer-EJ; Macdonald-N; Scott-JF; Scott-MR; Deachman-MJ; Mount-B
J-Palliat-Care. 1994 Summer; 10(2): 80-1


The treatment of suffering when patients request elective death.
Cherny-NI; Coyle-N; Foley-KM
J-Palliat-Care. 1994 Summer; 10(2): 71-9


Assisted suicide for depression: the slippery slope in action? [editorial]
Ogilvie-AD; Potts-SG
BMJ. 1994 Aug 20-27; 309(6953): 492-3



Report of the Board of Trustees of the American Medical Association. Euthanasia/physician-assisted suicide: lessons in the Dutch experience.
Issues-Law-Med. 1994 Summer; 10(1): 81-90

This Board of Trustees Reports urges physicians to be aware of continuing efforts by some in society to end suffering by speeding deaths through medical interventions. The experience in Holland with euthanasia and physician-assisted suicide is outlined in this report, as are the differing interpretations of the Dutch data by voices in Holland. The Dutch guidelines intended to protect patients have not been consistently respected. The sum of the experience suggests that implementation of their controls on euthanasia and physician-assisted suicide has not been effective. Recognizing that there are differences between withholding or withdrawing life-sustaining treatment and euthanasia and physician-assisted suicide, the availability of mechanisms for end of life medical decision-making by patients, such as powers of attorney, etc., should be more widely promoted. The Board of Trustees recommends that the American Medical Association reject euthanasia and physician-assisted suicide as being incompatible with the nature and purposes of the healing arts.

1993

The euthanasia/assisted suicide debate matures.
Byock-IR
Am-J-Hosp-Palliat-Care. 1993 Mar-Apr; 10(2): 8-11


When the dying demand death [editorial]
Roy-DJ
J-Palliat-Care. 1993 Winter; 9(4): 3-4


The concept of hope and the will to live.
Hockley-J
Palliat-Med. 1993; 7(3): 181-6

Hope is defined as a concept that suggests a greater emotional component than mere expectation, and is seen as an active process of conscious and unconscious reasoning. Hope is intrinsically linked with caring, and the professional role of the nurse can often influence the generation of hope or hopelessness in the care of patients. The appropriateness of removing all hope even within palliative care is questioned. A case study is presented in which a patient, requesting euthanasia, hovered on the brink of death yet would not die. For this patient all 'hope' of wanting to live had waned, yet she could not die. A new concept of 'rational no-hope' is postulated.


Two lawyers and a technician.
Randall-F
Palliat-Med. 1993; 7(3): 193-8

The major arguments used to support the legalization of euthanasia are that such a move would increase autonomy both for individuals and for society as a whole, and would diminish suffering. This paper examines these two points from several angles, and concludes that, from the standpoint of society as a whole, the legalization of euthanasia would be likely to achieve the complete opposite: a reduction in autonomy and an increase in overall suffering. The involvement of doctors in euthanasia is seen as a separate debate. The medical ethic of beneficence and its importance are discussed, together with the consequent dilemmas produced if this ethic is to be retained at the same time as requesting doctors to perform euthanasia. Consequences for the doctor-patient relationship in terms of loss of trust are described. To resolve these dilemmas it is suggested that, if euthanasia were legalized, initial assessment should be by two lawyers, and the act itself performed by a technician, suitably vocationally trained.


Why doctors and nurses must not kill patients
Pollard-B; Winton-R
Med-J-Aust. 1993 Mar 15; 158(6): 426-9

Euthanasia continues to be a subject of lively interest to many groups in society. It is often discussed in terms which appeal to those who believe there is no other way to relieve the sufferings of the dying, but which fail to explore its important ethical, professional and legal aspects. When these are examined, it is seen that the legalization of euthanasia would create major problems in medicine and nursing, chiefly centred on the likelihood of abuse and the difficulty or impossibility of its detection. It is now known from official sources that in Holland, the only place where euthanasia is widely practised though in defiance of the law, the authorities have no control over it, and it is indeed associated with many abuses, including the frequent killing of persons without their consent.


Consciously walking the fine line: thoughts on a hospice response to assisted suicide and euthanasia.
Byock-IR
J-Palliat-Care. 1993 Autumn; 9(3): 25-8


Euthanasia--widening the debate [editorial]
Kirkham-SR
Palliat-Med. 1993; 7(3): 179-80


Communicating with people who request euthanasia.
Cole-RM
Palliat-Med. 1993; 7(2): 139-43

The subject of euthanasia is widely debated in the medical literature and lay press in terms of morals, anecdotes and medical or legal ethics. This paper approaches the issue from a patient-centred perspectives, giving four case histories to demonstrate widely varied motives or hidden agendas for requesting euthanasia. It concludes with guidelines in an approach to communication which may empower the caregiver when confronted with a patient requesting assisted death or suicide.


The request for assistance in dying. The need for psychiatric consultation.
Baile-WF; DiMaggio-JR; Schapira-DV; Janofsky-JS
Cancer. 1993 Nov 1; 72(9): 2786-91

BACKGROUND. Public initiatives and legislative proposals have increased the likelihood that some states will legalize euthanasia and assisted suicide as a means of ending the suffering of patients with terminal illness. However, suggested safeguards that would guide physicians in such cases have not properly addressed the need to evaluate psychosocial factors that could motivate patients' requests for premature death. METHODS. Four cases of patients with cancer who expressed a wish to end their lives prematurely are described. These cases were evaluated with regard to mental and emotional functioning. RESULTS. Pain and suffering, organic mental disease, depression, and personality issues play significant roles in patients' requests for assistance in dying. CONCLUSION. Comprehensive psychosocial assessment is needed when evaluating requests for assistance in dying. This assessment may reveal hidden problems or conflicts that affect rational decision making, a prerequisite to informed consent for any procedure or intervention.


Dissociation between the wishes of terminally ill parents and decisions by their offspring
Sonnenblick-M; Friedlander-Y; Steinberg-A
J-Am-Geriatr-Soc. 1993 Jun; 41(6): 599-604

OBJECTIVE: To assess the attitude and factors affecting decision-making by offspring for life-sustaining measures toward their elderly terminally ill parents. DESIGN: Survey SETTING: Acute geriatric department of a university-affiliated teaching hospital. PATIENTS AND PARTICIPANTS: 108 offspring of 48 terminally ill elderly patients were interviewed. MEASUREMENTS: The attitude of offspring regarding life-sustaining measures based on a comprehensive questionnaire, administered by face-to-face interview, that included clinical, social, and religious information for each patient and social, religious, demographic, and educational information for each family member. RESULTS: A significant majority requested the continuation of fluid, nutrition, and medication (78%, 66%, 73%, respectively). A minority of 25%-29% requested the initiation of resuscitation, mechanical ventilation, and dialysis. Active euthanasia was requested by seven offspring. Factors that significantly affected offspring's decisions were the degree of religious observance and close relationship. Approximately 50% of offspring believed they knew their parents' wishes, but most of them did not comply with the parents' wishes. The offspring's preferences for themselves differed in important aspects from the requests for their parents. The great majority stated that a family member and/or the responsible physician should be involved in the decision-making process (76% and 79%, respectively). Only 2.0% suggested the participation of an ethics committee, and the court was rejected by all. CONCLUSIONS: Basic life-sustaining measures are requested for the terminally ill parents by most of the offspring. A significant minority even requested aggressive life-sustaining measures. The degree of religiosity and closeness of relationship influenced offspring's request most strongly.

1992


The final autonomy [editorial]
Lancet. 1992 Sep 26; 340(8822): 757-8

1991


Final Exit: a wake-up call to hospice.
Byock-IR
Hosp-J. 1991; 7(4): 51-66

The publication of Final Exit resulted in a public response that was exuberant, largely sympathetic and, to many within hospice, disquieting. The book and the public response it engendered can not be understood without exploring the Hemlock Society and the political agenda which both the Society and book advance. Hospice must begin a response to this book, and any discussion with Hemlock supporters, from a basis of consensus. Hospice must acknowledge that those within the euthanasia/assisted suicide movement believe as deeply as we in hospice in the need to address the suffering of people enduring the effects of terminal illness. We must further acknowledge that there remain unmet needs in the care of the dying which for primarily socio-political reasons hospice has been unable to resolve. There are several compelling reasons for hospice as an organized movement to oppose the political initiatives of the Hemlock Society--at least in their present form and within the current social context. These reasons involve core ethical issues and issues of direct social consequence, each of which seems sufficient to reject the current proposals. Hospice programs and personnel must enter this debate in earnest. Before serious consideration is accorded to legalization of euthanasia/assisted suicide, we must insist that genuine access to comprehensive hospice/palliative care becomes a reality for all dying patients and their families.


Relief of suffering: the doctor's mandate [editorial]
Roy-DJ
J-Palliat-Care. 1991 Winter; 7(4): 3-4


The relationship of pain and symptom management to patient requests for physician-assisted suicide.
Foley-KM
J-Pain-Symptom-Manage. 1991 Jul; 6(5): 289-97

Uncontrolled pain and multiple adverse symptoms compel some cancer patients with advanced disease to consider suicide or to request physician-assisted suicide as their only option. Any debate that focuses on the options to terminate life in patients with advanced disease must give adequate consideration to the existing level of care for patients with these distressing symptoms. Numerous studies have described the educational, attitudinal, and legislative barriers that exist and prevent patients from receiving acceptable pain and symptom management during their illness. Lack of knowledge about the use of analgesics, coupled with the lack of sophistication in diagnosing and treating the psychological complications of cancer, are examples of such educational barriers. Existing continuing care programs, like hospice, that manage symptoms in patients with far-advanced disease are currently insufficient to meet the needs of this large population. We need to address the access to expert care of distressing symptoms including pain and psychological distress as well as the quality of life of this patient population before we can fully address the options for terminating life.

1990

Euthanasia--a critique
Singer-PA; Siegler-M
N-Engl-J-Med. 1990 Jun 28; 322(26): 1881-3