Transcript First Do No Harm - Euthanasia in Belgium

First Do No Harm
Euthanasia in Belgium
Raphael Cohen-Almagor
July 18, 2015
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Definitions
• Euthanasia -- a practice undertaken by a physician,
which intentionally ends the life of a person at her explicit
request.
• Physician-assisted suicide is different than euthanasia in
that the last act is performed by the patient, not by the
physician. The physician provides the lethal drugs to the
patient who takes them by herself.
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Concerns
• (1) the changing role of physicians and
imposition on nurses to perform euthanasia;
• (2) the physicians’ confusion and lack of
understanding of the Act on Euthanasia;
• (3) inadequate consultation with an independent
expert;
• (4) lack of notification of euthanasia cases;
• (5) organ transplantations of euthanized
patients.
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Euthanasia - Law
• Belgium accepted the Dutch definition:
• (a) “euthanasia is the intentional taking of someone’s life
by another, on her request”.
• (b) It follows that this definition does not apply in the
case of incompetent people; there the proposed
terminology is “termination of life of incompetent
people”.
• (c) More importantly, the act of stopping a pointless
(futile) treatment is not euthanasia and it is
recommended to give up the expression “passive
euthanasia” in these cases.
• (d) What was sometimes called “indirect euthanasia”,
forcing up the use of analgesics with a possible effect of
shortening life, is also clearly distinguished from
euthanasia proper.
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Euthanasia - Law
• The patient’s physician needs to inform
the patient of the state of his/her health
and of his/her life expectancy;
• Discuss with the patient his/her request for
euthanasia and the therapeutic measures
which can still be considered as well as
the availability and consequences of
palliative care
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Consultation
• In both Belgium and Holland, the
physician practicing euthanasia is
required to consult an independent
colleague in regard to (a) the
hopeless condition of the patient, and
(b) the voluntariness of the request.
• Unclear to what an extent the
independency requirement has been
compromised.
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Role of Physicians and Nurses
• In both Belgium and Holland, the physician
is required to devote energies in the
patient and her loved ones, to consult with
other specialists, to spend time and better
the communication between all people
concerned.
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Palliative Care
• Role of the psychologist.
• Palliative psychiatry can be helpful in
managing symptoms alongside medical
and nursing staff, such as pain,
breathlessness, fatigue and treatment
side-effects; clarifying issues of personal
autonomy; coping with changes as a result
of the patient’s condition, and managing
feelings of uncertainty
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Who Administers the Lethal
Drug?
• The law clearly stipulates that only
physicians may administer the lethal drugs
for euthanasia.
• 12% of nurses in Flanders administered
the drugs, mostly without the physician coadministering
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Physicians’ Confusion and Lack of Understanding
of the Law
• Two out of 10 physicians failed to label a
hypothetical case in which a physician
ended the life of a patient at the patient’s
explicit request as “euthanasia.”
• Three out of 10 did not know that the case
had to be reported.
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Consultation
• In 35% of the cases (n=235) physicians
failed to consult an independent specialist.
• Disagreement between the first and the
second physician in 23% of cases.
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Consultation
• Since 2003, LEIFartsen in Belgium.
• In Belgium, there are no rules regarding who
decides the identity of the consultant.
• The only rule is that the consultant needs to be
independent.
• Probably doctors approach like-minded
physicians.
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Reporting
• In Belgium, all cases have to be fully documented in a
special format and presented to a permanent monitoring
committee, the National Evaluation and Control
Commission for Euthanasia, established by the
government in September 2002.
• The Commission needs to study the registered and duly
completed euthanasia document received from the
physician.
• Members ascertain whether euthanasia was performed
in conformity with the conditions and procedures listed in
law.
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Reporting
• According to the last report (2010)
approximately half (549/1040
(52.8%) of all estimated
cases of euthanasia were reported to the
Federal Control and Evaluation
Committee.
•
Timme Smets, Johan Bilsen, Joachim Cohen et al., “Reporting of Euthanasia in Medical Practice in Flanders,
Belgium: cross sectional analysis of reported and unreported cases”, BMJ, Vol. 341 (October 5, 2010).
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Organ Transplantations
• Organs of Belgian nationals or people who
have lived in Belgium for more than 6
months can be removed after death,
except if they have specifically stated
refusal while they were still alive, or the
deceased immediate family objects to it.
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Organ Transplantations
• Euthanasia can be planned.
• Euthanasia donors accounted for 23.5% of
all lung donors and 2.8% of heart
transplant donors after cardiac death.
• Euthanasia donors accounted for almost a
quarter of all lung donors while euthanasia
cases accounted for 0.49% of deaths.
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Suggestions for Improvement
•
Would there be need for euthanasia if
care were better organized?
• Culture of Death?
• Beneficence v. non-maleficence.
• Do No Harm!
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Palliative Care
• In Flanders, about 10,000 patients receive daily
palliative care.
• Insufficient financial support from the Belgian
government for local and national palliative care
initiatives and research;
• Lack of palliative care guidelines and standards
for palliative care education;
• Palliative day-care services is new;
• In Flanders, no specialist accreditation for
palliative care professionals.
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Palliative Care
• Palliative care knowledge and expertise of
the average physician is very limited.
• Most physicians have had no or very little
training in palliative care.
• The average general practitioner treats a
few dying patients each year and has little
experience in treating complex refractory
symptoms.
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Palliative Care
• While the existence of adequate palliative
care does not guarantee that patients
would opt for life, there is evidence that:
• referral to palliative care programs and
hospice results in beneficial effects on
patients' symptoms,
• reduced hospital costs,
• a greater likelihood of death at home,
• a higher level of patient and family
satisfaction than does conventional care.
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Palliative Care
• Patients with an enhanced sense of
psycho-spiritual well-being are able to
cope more effectively with their condition.
• Emotional distress, anxiety, helplessness,
hopelessness and fear of death all detract
from psycho-spiritual well-being.
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Palliative Care
• Comprehensive palliative care, which
includes anxiety relief, pain and symptom
management, support for the patient and
her loved ones, and the opportunity to
achieve meaningful closure to life, should
be the standard of care at the end of life.
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Expert Consultation
• independence should be studied and
reviewed’
• Who is the consultant?
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Expert Consultation
• LEIF exists only in small scale in Wallonia.
• 78.2% of physicians were aware of the
existence of LEIF but only 35% of
physicians who had received a euthanasia
request since LEIF became active had
made use of LEIF.
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The patient’s attending physician
• The patient’s attending physician, who
supposedly knows the patient’s case
better than any other expert, must be
consulted, and all reasonable alternative
treatments must be explored.
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The care-givers Team
• The care-givers should include specialist
physicians, nurses, social workers, mental
health professionals, rehabilitation
therapists and community-based
agencies.
• Quality care requires investing time and
attention, opening and maintaining twodual way communication of listening and
advising.
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Role of social workers
• It must be ensured that the patient’s
decision is not a result of familial and
environmental pressures.
• It is the task of the social workers to create
an open, supportive space in which the
patient can feel safe to hold a candid
conversation about her condition and
wishes.
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Conclusion
• Paternalism
• 60% of physicians think that they should
be able to decide to end the life of a
patient who suffers unbearably and is
incapable of making decisions.
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Holistic care
• Holistic care must be compassionate,
addressing the physical, psychological,
existential and spiritual aspects of the
patient’s dying experience.
• All cases of physician-assisted suicide
(PAS) and euthanasia should be
scrutinized, examined, monitored, and
studied carefully.
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Thank you
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