Physician aid-in-dying and euthanasia

Figure 22.1 Responding to requests for euthanasia or assisted suicide

assisted suicide are outlined in Fig. 22.1. First, these requests should be carefully listened to. Many requests for assisted death are expressions of suffering, and are withdrawn by patients after appropriate symptom management. However, this is not always the case. Although the controversies and emotions surrounding this topic can make these discussions difficult, remaining non-judgmental is important to patient management. The patient’s request should be discussed and clarified. If she is truly making a request to die, and is competent to make decisions, a structured discussion about advance care planning should take place, and the possibility of writing advance directives should be offered.

In all circumstances, suffering should be assessed using a holistic “total suffering” palliative care approach. Depression should be screened for and treated if present. Where available, specialized palliative care expertise should be offered. Whenever possible, symptom management should be handled by a team of healthcare providers with complementary expertise. When they are likely to be called upon for specific interventions, such as palliative sedation, anaesthesiologists should be included in discussions regarding their indication in the patient’s specific circumstances. Importantly, palliative sedation does not constitute assisted dying in the sense discussed in this chapter. In some cases, it can be a part of symptom management at this stage.

Many requests will be dropped following these steps. However, some do persist. In such cases, where a competent patient persists in asking to die despite appropriate management of suffering, several situations exist.

One is the situation where a patient is under life-sustaining therapy. Controversies surrounding treatment withdrawal tend to increase as the invasiveness of the intervention decreases: withholding food and water is often more controversial than withholding ventilator support. However, if any life-sustaining intervention is being applied, its refusal by a competent patient is usually considered sufficient grounds to withdraw it.

When no life-sustaining intervention is being used, the next steps will depend on the legal status of euthanasia or assisted suicide, and on the physician’s own convictions. Where assisted death is not legal, or in situations that do not fulfill legally described criteria, palliative sedation can again be considered as an alternative at this stage. Indeed, it is sometimes preferred even in areas where assisted death would be legal. Finally, even in situations where euthanasia or assisted suicide would be legally authorised, there is no duty on the part of physicians to perform either intervention. In countries where assisted death is legal, an objecting physician can refer the patient whose request persists to a colleague. Where it is known in advance that a physician would in any case refuse to assist death, this should be made clear to the patient as early as possible. It is of course important to be clear on this point both in countries where assisted death is legal, and in countries where it is not.

Key points

• Palliation with therapeutic intent, including palliative sedation, is not equivalent to assisted death even in cases where the treatment may hasten death.

• Physician assisted suicide and voluntary euthanasia are legal in some jurisdictions.

• Arguments against physician assisted death usually refer to a violation of the physician’s role and/or the potential for coercion of vulnerable patients.

• Arguments for physician-assisted death usually refer to beneficence and patient autonomy.

• Although many patients who request aid-in- dying are depressed, not all requests are associated with depression, nor does the presence of depression necessarily invalidate a request for aid-in-dying.

• Requests for aid-in-dying should be taken seriously and carefully listened to. Screening for and treatment of problematic symptoms and depression may lead to withdrawal of the request.

• When a request for aid-in-dying persists and no life-sustaining treatments are being employed, the response will depend on the legal status of euthanasia or assisted suicide, and on the physician’s own convictions.

References

1* Sprung, C.L., S.L. Cohen, P. Sjokvist, M., et al. (2003). End-of-life practices in European intensive care units: the Ethicus Study. JAMA, 290(6), 790–7.

2* Sprung, C.L., Maia, P., Bulow, H.H., et al. (2007). The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intens Care Med, 33, 1732–9.

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