Euthanasia and Physician-Assisted Suicide in Patients With Multiple Geriatric Syndromes

Berg, Vera van den; Thiel, Ghislaine J. M. W. van; Zomers, Margot; Hartog, Iris D.; Leget, C.J.W.; Sachs, A. P. E.; Uiterwaal, Cuno; Wijngaarden, Els van

doi:10.1001/jamainternmed.2020.6895

Cited by 29 publications

(20 citation statements)

References 14 publications

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“…Moreover, the documents used are abbreviated representations of complex cases, made suitable for publication on an open access website and selected for predominantly educational purposes. They contain “plain language” with little medical, social and historical context‐descriptions 3,27 . Since much standardized wording was used, we coded non‐standard texts with special attention.…”

Section: Discussionmentioning

confidence: 99%

“…The RTE select cases that (1) “are relevant for the further development of (ethical) norms or for the societal debate,” 26 that (2) provide insights into the “spectrum of cases reviewed and to contribute to the understanding of complex or controversial cases among physicians and the general public,” plus (3) some cases that are “considered common.” 27 After excluding dementia cases in which the main cause of suffering was not dementia, 111 cases were left to analyze.…”

Section: Methodsmentioning

confidence: 99%

“…For background purposes we collected quantitative data about (a) patient characteristics, (b) the timeline, (c) the setting, and (d) the RTE's interpretation of the legal criteria (Table 2 , and Tables S1 –S4). 27 For these case descriptions we chose variables used elsewhere. 3 …”

Section: Methodsmentioning

confidence: 99%

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The ethics of euthanasia in dementia: A qualitative content analysis of case summaries (2012–2020)

Groenewoud

Leijten

Oever

et al. 2022

J American Geriatrics Society

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Background The practice of euthanasia in dementia has thus far been described both in terms of its empirical patient characteristics and its ethical questions. However, 40 new cases have been published since the last study. Methods A qualitative content analysis of all 111 Dutch case summaries of euthanasia in dementia patients between 2012 and 2020, selected from the total of 1117 cases published by the Regional Euthanasia Review Committees (RTE). Our initial analytical framework consists of six due care criteria and five ethical principles. Results 111 case summaries were analyzed, from which we distilled seven recurring ethical questions: (1) How voluntary is a request? (2) Can an incapacitated patient make well‐considered requests? (3) What constitutes “unbearable suffering”? (4) What if the unbearableness of suffering solely consists of “the absence of any prospect of improvement”? (5) What if a euthanasia request is meant to prevent future suffering (now for then)? (6) How (well) can a patient with cognitive limitations be informed? (7) What are “reasonable alternatives” and what if patients decline available alternatives? Conclusions Beyond these questions, however, we also see some serious challenges for the future: (a) narrowing the gap between perceived and real nursing home quality, since many advance euthanasia directives refer to nursing homes as sources of unbearable suffering; (b) making information to incompetent patients and their relatives about end of life options more tailor made, since it is questionable whether patients with dementia currently understand all of the euthanasia procedure; (c) involving patients' own physician as long as possible in a euthanasia request. Training may help physicians to deal better with euthanasia requests by patients suffering from dementia; (d) longitudinal research is required that encompasses all dementia euthanasia cases, not only those selected by the RTE.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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The ethics of euthanasia in dementia: A qualitative content analysis of case summaries (2012–2020)

Groenewoud

Leijten

Oever

et al. 2022

J American Geriatrics Society

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“…Struggling with the age-related deterioration, he feels more and more disconnected from world around him, alternately unable or unwilling to reconcile himself with his estranged and resisting body. (based on the documentary Full Stop, 2020 1 ) Although most older adults succeed in finding meaning in life, even in deep old age (van Campen, 2020;van Campen & Verbeek-Oudijk, 2017), there is a minority of older adults who feel that life no longer makes sense (van Wijngaarden et al, 2015) As reflected in Michael's case, those people may suffer from the consequences of old age, explicated in feelings of loneliness, social isolation and disconnectedness, and fears for (further) decline and dependency. Consequently, some older adults may develop a wish to die (McCue & Balasubramaniam, 2017;Richards, 2017) + (van Wijngaarden et al, 2016;Hartog et al, 2020).…”

Section: Introductionmentioning

confidence: 99%

The Darker Side of Ageing: Towards an Ethics of Suffering that Emphasises the Primacy of Witnessing

Wijngaarden

2021

Population Ageing

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Many older adults succeed in finding meaning in life, even in deep old age. There is, however, a minority of older adults, in particular among the oldest old, who feel that life no longer makes sense: they suffer from the consequences of old age, explicated in feelings of loneliness, social isolation and disconnectedness, and fears for (further) decline and dependency. This article seeks to address this darker side of ageing. It discusses probing questions including: what can we learn from the stories of those who severely struggle with the consequences of old age? And how might these stories guide us in finding ways how we – both as fellow human beings and as a society – can face and respond to suffering in old age? To achieve this, this article first briefly outlines the scholarship on suffering and explores the idea of suffering from life in old age. Secondly, drawing on empirical work, it reflects on the phenomenological question: what is it like to suffer from life in old age? What does it mean to live with a deep sense that life is no longer worth living? Then, thirdly, building on these insights, the aim is to work towards developing an ethics of suffering that emphasises the primacy of witnessing. It is argued that in the confrontation with manifestations of meaninglessness and suffering that cannot be solved or remedied, we need bystanders who are willing to name, to narrate, to give voice and connect to these experiences of suffering.

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“…4 A recent qualitative study from the Netherlands reported that, among 53 patients who underwent MAiD for "multiple geriatric syndromes," a combination of medical, social and existential issues was often associated with unbearable suffering leading to the MAiD request in the absence of a life-threatening condition. 5 When considering MAiD for frail individuals, it is essential that clinicians address this complex constellation of contributing factors, some of which may be modifiable. For example, frailty related to social isolation, depression and food insecurity may need to be addressed differently than frailty from poorly controlled diabetes, congestive heart failure and recurrent falls.Assessments for frail individuals who request MAiD are challenging given ambiguities in the interpretation of whether frailty is irreversible and incurable, and whether it causes intolerable suffering.…”

mentioning

confidence: 99%

Considerations for assessing frail older adults requesting medical assistance in dying

Engelhart

Stall

Quinn

2022

CMAJ

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In 2016, medical assistance in dying (MAiD) was decriminalized in Canada with the passage of Bill C-14. Under Bill C-14, competent adults (aged ≥ 18 yr) with a serious and incurable condition in an advanced state of irreversible decline who were experiencing intolerable physical or psychological suffering and whose death was reasonably foreseeable could be eligible for MAiD. 1 After its passage, legal challenges were brought before the Superior Court of Quebec, who ruled that the original legislation was too restrictive and in violation of the Canadian Charter of Rights and Freedoms. 2 This led to the passage of Bill C-7 in March 2021, which amended Canada's criminal code to remove "reasonably foreseeable death" as an eligibility criterion, thus creating 2 distinct pathways for MAiD, where death either is or is not reasonably forseeable. 3 One patient population likely to be affected by these changes is older adults considered to be frail. Clinicians should consider whether factors contributing to frailty are reversible when considering requests for MAiD.MAiD for those in whom death is not reasonably forseeable is subject to additional safeguards including a minimum 90-day period for assessing eligibility and mandatory assessment by a clinician with expertise in the patient's condition. 3 Bill C-7 also permits MAiD through an advanced directive if eligibility was determined when the patient was capable, which is relevant for patients with dementia or those at high risk of developing delirium (both of which often co-exist with frailty).Frailty is a syndrome characterized by reduced physiologic reserve that renders an individual more susceptible to adverse outcomes in response to stressors. 4 Frailty is an underrecognized clinical entity that is distinct from normal aging. In frailty, an accelerated decline results from an accumulation of health deficits, leading to dysregulation of multiple systems over time. Many interrelated biological (e.g., genetics), clinical (e.g., under lying comorbidities) and socioeconomic (e.g., social isolation) factors contribute to this accelerated decline, with frailty being a final common pathway. 4 A recent qualitative study from the Netherlands reported that, among 53 patients who underwent MAiD for "multiple geriatric syndromes," a combination of medical, social and existential issues was often associated with unbearable suffering leading to the MAiD request in the absence of a life-threatening condition. 5 When considering MAiD for frail individuals, it is essential that clinicians address this complex constellation of contributing factors, some of which may be modifiable. For example, frailty related to social isolation, depression and food insecurity may need to be addressed differently than frailty from poorly controlled diabetes, congestive heart failure and recurrent falls.Assessments for frail individuals who request MAiD are challenging given ambiguities in the interpretation of whether frailty is irreversible and incurable, and whether it causes intolerable suffering. F...

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Euthanasia and Physician-Assisted Suicide in Patients With Multiple Geriatric Syndromes

Cited by 29 publications

References 14 publications

The ethics of euthanasia in dementia: A qualitative content analysis of case summaries (2012–2020)

The ethics of euthanasia in dementia: A qualitative content analysis of case summaries (2012–2020)

The Darker Side of Ageing: Towards an Ethics of Suffering that Emphasises the Primacy of Witnessing

Considerations for assessing frail older adults requesting medical assistance in dying

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