First Do No HarmFirst Do No HarmEuthanasia in Euthanasia in BelgiumBelgium

Raphael Cohen-AlmagorRaphael Cohen-Almagor

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DefinitionsDefinitions

• 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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ConcernsConcerns

• (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 - LawEuthanasia - 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 - LawEuthanasia - 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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ConsultationConsultation

• 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 NursesRole 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 CarePalliative 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 Who Administers the Lethal DrugDrug??

• 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 co-administering

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Physicians’ Confusion and Lack of Understanding Physicians’ Confusion and Lack of Understanding of the Lawof 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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ConsultationConsultation

• 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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ConsultationConsultation

• 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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ReportingReporting

• 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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ReportingReporting

• 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 TransplantationsOrgan 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 TransplantationsOrgan 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 ImprovementSuggestions for Improvement

• Would there be need for euthanasia if care were better organized?

• Culture of Death?

• Beneficence v. non-maleficence.

• Do No Harm!

Palliative CarePalliative 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 CarePalliative 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 CarePalliative 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 CarePalliative 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 CarePalliative 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 ConsultationExpert Consultation

• independence should be studied and reviewed’

• Who is the consultant?

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Expert ConsultationExpert 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 physicianThe 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 TeamThe 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 two-dual way communication of listening and advising.

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Role of social workersRole 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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ConclusionConclusion

• 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 careHolistic 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 youThank you

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