bulletAssisted suicide Zurich
bullet Belgian euthanasia bill gains momentum  
bulletFrance:  Withholding and withdrawal of life support in intensive-care units
bulletNearly One in Five ICU Deaths Misdiagnosed NEW YORK
bulletStudy Shows Doctors Handle Suicide Requests Alone

bullet

Assisted suicide in Zurich

The Swiss Hippocratic Society is demanding that Zurich city council reverse a decision to allow assisted suicide in institutions for the elderly and infirm, excluding hospitals. The new provisions let right-to-die societies provide lethal drug cocktails for mentally capable people who have repeatedly expressed the wish to die.

Euthanasia is illegal in Switzerland, but assisted suicide is tolerated. ''The sick, the old and the suicidal need protection and support from society, not poison'', said a large newspaper advertisement Dec 23, 2000 placed by the Society and signed by nearly 400 doctors and other professionals.

SOURCE: Policy and people:   Clare Kapp Volume 357, Number 9249 06 January 2001 The Lancet http://www.thelancet.com/search/search.isa

bullet

 Belgian euthanasia bill gains momentum

On Jan 20, the euthanasia commission of Belgium's Senate voted in favour of proposed euthanasia legislation, which would make euthanasia no longer punishable by law, provided certain requirements are met.

The patient must request euthanasia, the suffering must be unbearable, and the clinical course hopeless, states the new legislation. An independent physician must be consulted, and a third physician must be brought in for non-terminal cases. "We are not happy with this last requirement, as we see no difference in suffering from a terminal illness versus a non-terminal one", says Léon Favyts, chairman of the Belgian Society for the Right to Die with Dignity, Antwerp, Belgium. "On the other hand we do appreciate that this was the maximum attainable in the present political climate.

Passing this crucial article paves the way for a Belgian euthanasia law after a long period in which the issue was not even debatable", says Favyts. Under current Belgian law euthanasia is a criminal offence. Despite this, recent research (see Lancet 2000; 356 1806-11) shows that euthanasia is widely practised. However, a public debate on euthanasia was only started in 1997 when the Belgian Council for Bioethics recommended legalisation for euthanasia. It seems that progress to a complete euthanasia law will be slow.

The latest amendment took one year of discussion in the Senate commission. "And the commission has yet to address another nine articles", says Herman Nys, Centre for Biomedical Ethics, Leuven, Belgium, "including the issues of a written declaration of intent and a procedure for retrospective checks. One article proposes a national 16-member committee to check all euthanasia cases with the possibility of turning over the case to a prosecuting attorney. This will stir another fierce debate because critics will argue that this will discourage doctors from reporting euthanasia. When all 12 articles have passed the commission the proposals will be voted on in the plenary Senate and the Belgian parliament. A decision on the bill is not expected before the summer.

Wim Weber

Policy and people: The Lancet Volume 357, Number 9253 03 February 2001

http://www.thelancet.com/search/search.isa

UPDATE: Belgium ready to vote on euthanasia law BRUSSELS, March 21 (Reuters) -

Belgian lawmakers have agreed on a draft law to legalise euthanasia in certain cases, subject to approval by parliament later this year. Tuesday's vote was split 17 to 12 with one abstention. The law, under consideration for about a year, has been subject to public hearings, beginning last May, and to considerable legal wrangling, with the Christian Democrats staunchly opposed to legalisation and the Socialist-Liberal-Green coalition advocating the right-to-die.

If passed, it would make Belgium the second country after the Netherlands to vote to legalise euthanasia. The Belgian proposal is similar to the Dutch legislation. Senators from two parliamentary working groups agreed to the final text of a draft law to legalise two types of requests for euthanasia -- by terminally ill patients and by patients with incurable diseases who may have years to live but are in extreme pain.

The draft legislation is expected to be presented to the upper house of parliament within the next month, said Senator Frans Lozea, who took part in the debate. "The lower house will then vote quite quickly afterwards," Lozea told Reuters on Wednesday. The government has given politicians a free vote on this issue, meaning they are not bound by their party's position. Under the proposed legislation, requests for euthanasia must be made by a patient who is conscious when making an active, voluntary demand. The request must also be persistently repeated. 13:44 03-21-01

Source Belgium ready to vote on euthanasia law , March 21 2001 (Reuters) -

bulletFRANCE

A more exhaustive survey of the "Withholding and withdrawal of life support in intensive-care units in France appears in Lancet Volume 357, Number 9249  06 January 2001 - by Edouard Ferrand, René Robert, Pierre Ingrand, François Lemaire, for the French LATAREA group*

In this study, Edouard Ferrand et., al expressed concern that "Reports of
clinical studies and guidelines have been published, in the USA especially, to govern and justify the withholding or withdrawal of life-saving treatments."  But found that  "there are no such guidelines in France, where the relationship between patient and physician is limited to a traditional paternalism, based on the principle of beneficence."

We observed obvious ethical limitations in the life-sustaining treatment decision-making processes. First, only 54% of the cases involved the nursing staff. Although many US papers have recommended participation of the nursing staff in ethical decisions, . . . involvement of nurses has varied from 16% in a Canadian study19 to 52% in a European questionnaire21 and to almost 96% in a UK study.22

Second, a substantial portion (12%) of decisions to limit care were taken by a single physician, with no consultation with the medical or nursing staff.21

A third worrying finding of this study was that 2% of the decisions were taken by a physician who was not a permanent member of staff. In addition, 11% of the decisions were taken during night shifts, which suggests at least some degree of haste.

Fourth, only 42% of decisions were notified in the medical record, which may reflect the reluctance of physicians to record their decisions in the French legal circumstances. Fifth, the frequency of decisions varied across ICUs from zero to 26%. Variability was also noticed in a large US study (deaths after such decisions varied from 4% to 79%).4 However, the effect of severity scores on mortality after life-support treatment had been withheld or withdrawn was not assessed in that study.4 We found that decisions to withhold and withdraw life-support therapies were strongly related to SAPS II, a marker of severity and a predictor of death; thus, differences in severity, case-mix, and referral may explain, at least partly, the differences between ICUs. However, a significant difference persisted after adjustment for SAPS II. Further studies are needed to investigate whether this variability across centres is due to differences in care-providers' motives and behaviours, which could seriously influence decisions on withholding or withdrawal of life-support therapies, as found in Canada.23

This in-depth study is worth reading;  Withholding and withdrawal of life support in intensive-care units in France The Lancet Volume 357, Number 9249
06 January 2001 http://www.thelancet.com/search/search.isa


URL FOR HOME PAGE LANCET http://www.thelancet.com/home

bulletNearly One in Five ICU Deaths Misdiagnosed NEW YORK

 Nearly one in five people who die in the intensive care unit (ICU) turn out to have been misdiagnosed according to autopsy results, researchers report. In a new study, Dr. Alejandro C. Arroliga from The Cleveland Clinic Foundation in Ohio and colleagues looked at the medical charts of more than 400 patients who died in the ICU over a 2-year period. Their findings are published in the February issue of the journal Chest. Ninety-one of the patients underwent an autopsy, and in 20% of cases the cause of death suggested that the patient had been misdiagnosed when they were alive. Of those cases, 44% had a major misdiagnosis and the patient would have had different treatment when they were alive if they had been correctly diagnosed, the report indicates. The current findings show that ``advances in diagnostic technology have not diminished the value of autopsy,'' Arroliga stated.

SOURCE: Chest 2001;119:530-536.

bulletStudy Shows Doctors Handle Suicide Requests Alone

By Will Dunham  Tuesday March 13 548 PM ET

WASHINGTON (Reuters) - Doctors whose terminally ill patients ask for help in ending their lives areoften forced by an ``unspoken code of silence'' to decide on the request alone, without the advice of fellow physicians, researchers said on Tuesday.

In a study published in the Archives of Internal Medicine (news - web sites), researchers interviewed doctors in Seattle and San Francisco who had received at least one request from a terminally ill patient for help in committing suicide. Half of the doctors had helped a patient to die, while the other half had not.

Dr. Jeffrey Kohlwes, who led the study, said the most surprising finding was that doctors rarely discussed the suicide requests with other doctors.

``Most physicians who received these requests really dealt with them alone. They perceived an unspoken code of silence on the topic among their colleagues,'' Kohlwes, a doctor at San Francisco Veterans Affairs Medical Center and a professor at the University of California San Francisco, said in a statement.

Although doctor-assisted suicide is against the law in every U.S. state but Oregon, doctors who care for terminally ill patients regularly hear suicide requests from patients, the researchers said. But there has been little documentation of how these requests are handled, they said.

The study was based on interviews with 20 doctors. A heavy emotional burden accompanied the isolation experienced by the doctors, Kohlwes said. A few said they were worried about becoming known publicly as the ``local Kevorkian,'' Kohlwes said,referring to Dr. Jack Kevorkian (news - web sites), an assisted-suicide crusader convicted in 1999 of second-degree murder in Michigan.

Doctors said they had the most difficulty dealing with requests from patients who wanted to die because their lives had become devoid of meaning, not because they were undergoing unbearable pain or suffering.

Kohlwes said most requests for a doctor's help in suicide could be handled by simply treating physical pain or depression.

``Most physicians we interviewed used these requests as a warning flag to aggressively treat a patient's physical discomfort, and in many cases they felt this was effective,'' he said. Most doctors in the study reported treating their patients with antidepressants.

Source: http://dailynews.yahoo.com/h/nm/20010313/sc/health_suicide_dc_2.html

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