SAVES is not affiliated with Exit International / Dr Philip Nitschke and opposes the public availability of a 'peaceful pill'.

Recent end-of-life surveys - Information from professional journals

(1) End-of-life decision making in six European countries

The authors of a report in The Lancet, ⁽¹⁾ aimed to investigate the frequency and characteristics of end-of-life decision-making in the Netherlands, Belgium, Denmark, Switzerland, Sweden and Italy. The report, covering the period June 2001 to February 2002, predates the new law in the Netherlands, which allows for voluntary euthanasia under prescribed guidelines. The research is based on more than 20,000 deaths registered in these countries. ⁽²⁾ Half the deaths reviewed were of people over 80 years of age, and cardio-vascular and malignant diseases were the most frequent causes of death. Survey findings include:

• End-of-life decision discussion with patients and relatives for competent patients was highest in the Netherlands
• End-of-life decision discussion or previously expressed wish for incompetent patients was highest in the Netherlands and Switzerland
• End-of-life decision discussion or previously expressed wishes by incompetent patients was discussed with relatives most frequently in the Netherlands and Belgium
• Written 'living wills' were available for fewer than 5% of patients in all countries apart from the Netherlands, where 13% were available
• Doctors consulted colleagues concerning end of life decisions for about 40% of all patients in the Netherlands, Belgium and Switzerland and for fewer than 20% in the other countries.
• Nursing staff were consulted most frequently in Belgium and Switzerland

The discussion reveals that, in all participating countries, end-of-life decision making is employed in two thirds of all deaths. (One third of deaths occur spontaneously). The administration of drugs with explicit intention of hastening death is practiced in all of the above-mentioned countries. The relatively high rate in the Netherlands is largely attributable to patient requests for voluntary euthanasia. Decisions made to hasten death as a medical response to suffering, but without explicit request of the patient, appear to be practiced within all modern healthcare regimes.

However the frequency of decisions based on cultural factors including patient autonomy, the determination of medical futility and the legal status of decisions vary between countries. Fifty one percent of deaths in Switzerland resulted from the outcomes of end-of-life decision making compared with 23% in Italy, 38% in Belgium, 41% in Denmark, 44% in the Netherlands and 36% in Sweden.

Results show that many medical procedures at the end of life are not appreciated by patients who experience 'less than optimum' communication regarding their circumstances. Despite medical advances many dying patients experience suffering. The authors call for further exploration of the variance in end-of-life decision-making to enhance a growing understanding that 'a peaceful death seems to be widely recognised as an important goal, in addition to more traditional goals such as curing disease and avoiding premature death'.

References:

1. van der Heide, A; Deliens, L; Faisst, K; Nilstun, T; Norup, M; Paci, E; van der Wal, G; van der Maas, P; (2003) 'End-of-life decision-making in six European countries: descriptive study' The Lancet, published online June 17 2003 http://image.thelancet.com/extras/03art3298web.pdf
2. 'Doctor-assisted euthanasia common in Europe' Agence France - Presse 4th Aug 2003

(2) Oregon nurses survey: refusal of food and fluids

A survey of nurses employed by hospice programmes in Oregon, and reported in The New England Journal of Medicine ⁽¹⁾ revealed that 33% of respondents had, over the past four years, cared for a patient who had elected to hasten their death by refusal of food and fluids. These patients considered their quality of life poor and were ready for death. Eighty five percent of patients died within fifteen days and experienced what was regarded as a 'good death'.

The cohort of patients refusing food and fluids had a median age 10 years older than those who elected to die by physician-assisted suicide (74 years compared with 64 years). They were also less likely to seek control over the circumstances of their death and were far less likely to have been evaluated by a mental health professional (9% compared with 45%). Death by starvation occurs much more quickly at the end stages of terminal illness than in a healthier person, as normal thirst and hunger mechanisms may not be intact.

This option in dying represents only a tiny minority of all deaths, possibly 0.03%. However in legislative climates where assisted death remains problematic, it is an option available to all competent patients.

(Emphasis added - Ed)

Reference:

1. Ganzini, L; Goy, E R; Miller, L; Harvath, T, Jackson, A; Delorit, MA; (2003) 'Nurses Experiences with Hospice Patients Who Refuse Food and Fluids to Hasten Death', The New England Journal of Medicine, Vol 349 No 4, pp359-365 July 24 2003

(3) Voluntary euthanasia and bereavement

Recent research conducted in Utrecht in the Netherlands ⁽¹⁾ had as its objective the assessment of how a chosen death by euthanasia in terminally ill cancer patients affects the grief response of bereaved family and friends. Results show that the bereaved family and friends of those who died by euthanasia experienced less traumatic grief symptoms, less current feeling of grief, and less post-traumatic stress reactions than those who died of natural causes.

Extraneous factors may explain the differences between the two groups - for instance the different personality traits between those who request euthanasia and those who do not; and also those of their respective families. The ability to acknowledge the terminal prognosis may be another factor. The authors claim that prognostic denial is more likely in those with an underlying distress, and this may also impact on the bereaved family. Colluding in prognostic denial may have a detrimental impact on the grief processes of the bereaved family and friends.

The conclusion is that more positive responses from bereaved whose loved ones chose voluntary euthanasia may relate to the opportunity to say goodbye while still fully aware, and being more prepared for the mode and timing of death. Having the ability to talk more openly, because the patient has broached the issue through their request for voluntary euthanasia, is another factor.

The authors claim that this survey does not represent a plea for euthanasia per se, but a plea for the same level of care and openness for all terminally ill patients. 'There is a need for awareness of impending death and for careful and thoughtful planning for where and how the death ought to occur'.

Reference:

1. Swarte, N; van der Lee, M; van der Bom, J; et al (2003) 'Effects of euthanasia on the bereaved family and friends: a cross sectional study', British Medical Journal 327:189 26 July

(4) Assisted suicide and the law

The latest edition of Medicine Today examines the question 'does merely being present at a euthanasia suicide count in the eyes of the law as assisting a suicide?' ⁽¹⁾ While the legal status-quo remains the same until changed by legislation, it is argued that there may be scope for judicial decisions which determine that 'some acts are crimes and others are not'. For instance the law on abortion has been changed by judicial interpretation. However this does not offer a clear precedent for the issue of assisted suicide. This is because, in the case of abortion, statutes prohibit what is declared to be 'unlawful abortion', but there is less scope for judicial interpretation of legislation prohibiting assisted suicide, as it is always considered unlawful.

However other arguments may be employed. For instance those attending a suicide may state that it cannot be proved that they have criminal intent, which is arguably implied in law. Also those attending may not have wished that the person commit suicide but did not want them to die alone.

The article states that if those at Nancy Crick's bedside are prosecuted 'judges will be required for the first time in Australia to decide whether intention must be proved as an element of the offence of assisting suicide. To that extent the use of civil disobedience will have been successful in clarifying the law.' Yet this particular case is taking a long time to be resolved and there is no indication of when the law might be clarified.

A decision not to prosecute remains one of discretion rather than one based on precedent. While it may be determined that being charged with assisting suicide requires proof of intention, such a judgement will be open to appeal. Nevertheless for those who advocate choice for the hopelessly and terminally ill this may still be considered a step forward.

Reference:

1. Skene, L; Nisselle, P (2003) ' Can civil disobedience change the law on assisting suicide?' Medicine Today, Vol 4 No 8 69 1 Aug