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Now that assisted suicide and euthanasia is legal, what Canadians can expect: Literature review

The arbitrary second deadline set by the Supreme Court of Canada for the coming into force of its arbitrary and senseless decision to invalidate Criminal Code protections against assisted suicide and euthanasia has arrived. Unless further extended, as of today Canadians wishing to commit suicide but too squeamish to do so themselves can take a shot at finding a doctor to kill them.

While the government will likely make the case for pushing through its proposed legislation, Bill C-14 a.k.a. the Medical Assistance in Dying Bill, it will have little practical effect. While presented as taking a conservative approach by only allowing individuals whose “death is reasonably foreseeable” to consent to being killed, Bill C-14 contemplates extending such consent to “mature minors” and those with mental illness within less than 180 days after it’s passed.

So what can Canadians expect to flow from this ill-considered decision to legalise consent to being killed? Unfortunately, a review of the literature in jurisdictions that legalised assisted suicide and euthanasia prior to Canada isn’t encouraging.

Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls
Euthanasia or assisted suicide – and sometimes both – have been legalized in a small number of countries and states. In all jurisdictions, laws and safeguards were put in place to prevent abuse and misuse of these practices. Prevention measures have included, among others, explicit consent by the person requesting euthanasia, mandatory reporting of all cases, administration only by physicians (with the exception of Switzerland), and consultation by a second physician. The present paper provides evidence that these laws and safeguards are regularly ignored and transgressed in all the jurisdictions and that transgressions are not prosecuted. For example, about 900 people annually are administered lethal substances without having given explicit consent, and in one jurisdiction, almost 50% of cases of euthanasia are not reported. Increased tolerance of transgressions in societies with such laws represents a social “slippery slope,” as do changes to the laws and criteria that followed legalization. Although the initial intent was to limit euthanasia and assisted suicide to a last-resort option for a very small number of terminally ill people, some jurisdictions now extend the practice to newborns, children,and people with dementia. A terminal illness is no longer a prerequisite. In the Netherlands, euthanasia for anyone over the age of 70 who is “tired of living” is now being considered. Legalizing euthanasia and assisted suicide therefore places many people at risk, affects the values of society over time, and does not provide controls and safeguards.

Killing us softly: the dangers of legalizing assisted suicide
This article is an overview of the problems with the legalization of assisted suicide as public policy. The disability community’s opposition to assisted suicide stems in part from factors that directly impact the disability community as well as all of society. These factors include the secrecy in which assisted suicide operates today, in states where it is legal; the lack of robust oversight and the absence of investigation of abuse; the reality of who uses it; the dangerous potential of legalization to further erode the quality of the U.S. health care system; and its potential for other significant harms. Legalizing assisted suicide would augment real dangers that negate genuine choice and self-determination. In view of this reality,we explore many of the disability-related effects of assisted suicide, while also addressing the larger social context that inseparably impacts people with disabilities and the broader public. First, after addressing common misunderstandings, we examine fear and bias toward disability, and the deadly interaction of assisted suicide and our profit-driven health care system. Second, we review the practice of assisted suicide in Oregon, the first U.S. state to legalize it, and debunk the merits of the so-called Oregon model. Third and finally, we explore the ways that so-called ‘‘narrow’’ assisted suicide proposals threaten inevitable expansion.

Euthanasia: The role of good care
The results from two surveys in England of relatives and others who knew people in samples drawn from death certificates are reported. The main focus is on a sample of 3696 people dying in 1990 in 20 health authorities, with supporting analysis from an earlier national sample of 639 people dying in 1987,The argument that good care and, in particular, hospice care is effective in reducing the desire for euthanasia has been proposed as an argument against the legalization of voluntary euthanasia. The findings suggest that the picture is in fact more complex. People who received hospice care were, if anything, more likely to have respondents who felt that it would have been better if they had died earlier. The latter held when controlling for other variables found to influence respondents’ views, such as the level of distress and dependency experienced by the dying person. It appears possible that the same may apply to the dying peoples’ own wishes, although here the time order of events could not be controlled for in the data. It is suggested that this may be due to hospice care being geared to helping patients express their fears and exercise choice. The wish for euthanasia may then be an assertion of personal control, rather than an act of surrender. Alternatively, people (and their relatives) who accept hospice care may be predisposed to consider the benefits of an earlier death. Measures of the quality of care and, where appropriate, symptom relief, from general practitioners, nursing and other domiciliary services, and care in other institutions such as old peoples’ homes and hospitals showed only a few and weak associations with the wish to die earlier or requests for euthanasia. Several measures of unmet need for domiciliary services and for treatment for symptoms were associated with the dependent variables. It is suggested that care that is judged to be good may only do a little to counteract peoples’ fear of dependency, and indeed might serve to increase feelings of lost autonomy

Euthanasia in Palliative Care Journals
With the growth of palliative care services, interest in moral issues also seems to be growing. The controversial issue of euthanasia significantly provokes moral reflection on the care for dying patients. This article presents an analysis of the moral issue of euthanasia as it is discussed by the palliative care community in the professional journals of palliative care. Initially, the analysis will focus on describing the characteristics of the publications about euthanasia and the attitudes expressed in the articles towards this practice. Second, attention will be paid to the description of the uses of the term euthanasia in the various articles and also how frequently such uses occur. Third, the various arguments in support for or against a place for euthanasia in palliative care will be discussed.

Euthanasia: Historical, Ethical, and Empiric Perspectives
Debates about the ethics of euthanasia date from ancient Greece and Rome. In 1870, S. D. Williams, a non-physician, proposed that anesthetics be used to intentionally end the lives of patients. Between 1870 and 1936, a debate about the ethics of euthanasia raged in the United States and Britain. These debates predate and invoke different arguments than do debates about euthanasia in Germany. Recognizing the increased interest in euthanasia, this article reviews the definitions related to euthanasia, the historical record of debates concerning euthanasia, the arguments for and against euthanasia, the situation in the Netherlands, and the empirical data regarding euthanasia in the United States.

End-of-life care across Southern Europe: A critical review of cultural similarities and differences between Italy, Spain and Portugal
Evidence from a range of sources demonstrates that end-of-life (EoL) care practices and preferences vary across countries; culture is consistently one of the main explanations given for this. In order to understand how cultural factors are used to explain similarities and differences in EoL care between Spain, Italy and Portugal, database and hand searches were performed and cross-cutting core themes identified. Similarities included higher proportions of people who wished to die at home than actually died at home, a persistent trend for partial disclosure in Italy and Spain, low use of advance directives, and low incidence of all medical EoL decisions (with the exception of terminal sedation) compared to northern European countries. The role of religion and the importance of family ties were the two main cultural factors used to explain the similarities. Further research is needed in order to interpret the important differences that were also found.

Concerns About End-of-Life Care and Support for Euthanasia
Popular support for euthanasia is known to vary according to socio-demographic characteristics. However, little is known about whether support is associated with concerns regarding the emotional,physical, and economic burdens of end-of-life care. This study used data from the 1998 General Social Survey, a national survey of community-dwelling adults. The outcome variable assessed the respondents’ support for a doctor’s right to end life in the setting of terminal illness. Independent variables assessed the following concerns: 1) concern about the emotional burden of end-of-life decision-making for family members; 2) worry about the economic burden of terminal illness; 3) concern about pain at the end of life; 4) worry that lack of money or insurance will result in second-class end-of-life care; and 5) belief that their religious community will be helpful at the end of life. Multi-variable logistic regression estimated the independent effect of these concerns on support for euthanasia, adjusting for socio-demographic characteristics. Of 786 respondents, 70.6% approved of euthanasia in the setting of terminal illness. In adjusted analyses, respondents with concerns about the emotional toll of decision-making on family members, economic burden, and poor health care because of lack of insurance were significantly more likely to support euthanasia. Respondents with faith in the helpfulness of their religious community were less likely to support euthanasia. In conclusion, emotional and economic concerns about end-of-life care were associated with support for the right to euthanasia. Future work can evaluate whether alleviating these concerns may reduce the perceived desire for euthanasia by patients near the end of life.

Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands
Background and Methods The characteristics and frequency of clinical problems with the performance of euthanasia and physician-assisted suicide are uncertain. We analyzed data from two studies of euthanasia and physician-assisted suicide in the Netherlands (one conducted in 1990 and 1991 and the other in 1995 and 1996), with a total of 649 cases. We categorized clinical problems as technical problems, such as difficulty inserting an intravenous line; complications, such as myoclonus or vomiting;or problems with completion, such as a longer-than-expected interval between the administration of medications and death.
Results In 114 cases, the physician’s intention was to provide assistance with suicide, and in 535, the intention was to perform euthanasia. Problems of any type were more frequent in cases of assisted suicide than in cases of euthanasia. Complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively. The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent),which thus be-came cases of euthanasia. The reasons for this decision included problems with completion (in 12 cases) and the inability of the patient to take all the medications (in 5).
Conclusions There may be clinical problems with the performance of euthanasia and physician-assisted suicide. In the Netherlands, physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient’s inability to take the medication or because of problems with the completion of physician-assisted suicide.

Belgian euthanasia law a critical analysis
Some background information about the context of euthanasia in Belgium is presented, and Belgian law on euthanasia and concerns about the law are discussed. Suggestions as to how to improve the Belgian law and practice of euthanasia are made, and Belgian legislators and medical establishment are urged to reflect and ponder so as to prevent potential abuse.

A critical review of advance directives in Germany Attitudes use and healthcare professionals’ compliance
Objective: Recent legal changes in Germany make non-compliance with advance directives (ADs) a criminal offence. This article assesses the evidence on attitudes towards, use of, and physician compliance with ADs in Germany.
Methods: Critical review: studies on ADs, identified from a systematic review of culture and end-of-life care in Germany (11 electronic databases, 3 journals, reference lists, and grey literature), were included. An interpretative synthesis of findings revealed cross-cutting themes.
Results: Thirty-two studies (1996–2009) were identified. Key themes were: awareness; utilization; compliance; and bindingness of ADs. There was a positive trend between awareness of ADs and study publication date. Use varied between patient groups (0.3–62%) and was low amongst the general population (2.5–10%). Fears about ADs’ purpose and possible abuse were identified. Physician discomfort in discussing ADs and non-compliance were reported. Physicians preferred legally binding ADs, though conflicting results were reported for patients’ desired level of bindingness.
Conclusion: Although there is increasing awareness of ADs in Germany, there remains low use, poor communication, fears of abuse, some non-compliance and contradictory evidence regarding desired bindingness.
Practical implications: Although legal changes will hopefully improve compliance, low awareness, communication difficulties and uncertainties surrounding ADs must be addressed if use is to increase.

The Relationship of Pain and Symptom Management to Patient Requests for Physician-Assisted Suicide
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.

The prevention of euthanasia through palliative care: New developments in The Netherlands
Dutch palliative care stands on the eve of important changes. Further development of palliative care has become part of official national health care policy. One of the aims is prevention of euthanasia. Through an expansion and improvement of palliative care facilities it is trying to rule out the possibility that future requests of euthanasia might be brought about through insufficient and inadequate palliative care. This paper focuses on these new developments in The Netherlands. It first discusses the recent developments with regard to euthanasia. Thereafter, it describes the dynamic setting of palliative care. Finally, the issue of prevention of euthanasia through palliative care is analyzed. With regard to this topic, two questions need to be carefully distinguished. On the one hand, there is the factual question of whether a further development of palliative care can prevent euthanasia, on the other hand we have the normative question of whether palliative care should be further developed to prevent euthanasia. Both questions are analyzed.

Systematic Review of the Primary Research on Minority Ethnic Groups and End-of-Life Care From the United Kingdom
Context. Patients from minority ethnic groups experience lower rates of referrals to end-of-life (EoL) care services, higher levels of dissatisfaction with services, and perceive some services as culturally inappropriate.
Objectives. To systematically review original studies of minority ethnic groups and EoL care in the U.K. and appraise their quality.
Methods. Searches were carried out in 13 electronic databases, eight journals, reference lists, and the gray literature. Studies of minority ethnic groups and EoL care in the U.K. were included. Studies were graded for quality and key themes were identified.
Results. Forty-five studies met inclusion criteria. Study quality was good on average. Identified key themes included age structure; inequality by disease group; referrals; caregivers; place of care and death; awareness of services and communication; and cultural competency. Strategies described for the reduction of inequities were partial and reactive. The format of 10 studies prevented quality grading; these were, however, reviewed as they provided unique insights. Variations in terminology and sampling frames complicated comparison across studies.
Conclusion. The results highlight the multiple and related factors that contribute to low service use and substandard quality of services experienced by minority ethnic groups, and the need for authors to clarify what they mean by ‘‘culturally competent’’ EoL care. The synthesis of diverse and disparate studies underpins a number of key recommendations for health care professionals and policymakers. Tackling these epidemiological, demographic, institutional, social, and cultural factors will require a systematic and organization-wide approach rather than the current piecemeal and reactive interventions.

Patient Requests for Euthanasia and Assisted Suicide in Terminal Illness The Role of the Psychiatrist
Psychosocial assessment and treatment are critical elements of care for terminally Ill patients who desire hastened death. Most patients, in saying that they want to die, are asking for assistance in living–-for help in dealing with depression, anxiety about the future, grief, lack of control, dependence,physical suffering, and spiritual despair. In this article, the authors review current understandings of the psychiatric aspects of requests by terminally ill patients for assisted suicide and euthanasia; describe an approach to the common problems of physical, psychological, social, and spiritual suffering encountered in managing dying patients; and elaborate the functions of the psychiatrist in addressing these problems.

Pain, Physician-assisted Suicide, and Euthanasia
Pain is only one of the compelling factors that lead patients to request physician-assisted suicide and euthanasia. Uncontrolled symptoms, psychological distress, and existential suffering appear to be equally profound elements in patient suffering. There is a strong consensus that physicians remain inadequately trained to care for the dying and deterred economically from providing humane,compassionate care to this group of patients. The institutionalization of death has further exacerbated and exalted the role of physicians in regulating death. Improved physician-patient communication,respect for patient-centered care, better physician judgment to withdraw or withhold care, and familiarity with the principles and practices of palliative care would definitely reduce the need to legalize physician-assisted suicide and euthanasia.

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