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First Do No Harm Euthanasia in Belgium


First Do No Harm Euthanasia in Belgium Raphael Cohen-Almagor * * Definitions Euthanasia -- a practice undertaken by a physician, which intentionally ends the life of ... – PowerPoint PPT presentation

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Title: First Do No Harm Euthanasia in Belgium

First Do No HarmEuthanasia in Belgium
  • Raphael Cohen-Almagor

  • 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.

  • (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
  • (4) lack of notification of euthanasia cases
  • (5) organ transplantations of euthanized patients.

Euthanasia - Law
  • Belgium accepted the Dutch definition
  • (a) euthanasia is the intentional taking of
    someones 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.

Euthanasia - Law
  • The patients 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

  • 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.

Role 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.

Palliative 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 patients condition, and managing
    feelings of uncertainty

Who Administers the Lethal Drug?
  • 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

Physicians Confusion and Lack of Understanding
of 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 patients explicit
    request as euthanasia.
  • Three out of 10 did not know that the case had to
    be reported.

  • In 35 of the cases (n235) physicians failed to
    consult an independent specialist.
  • Disagreement between the first and the second
    physician in 23 of cases.

  • 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
  • Probably doctors approach like-minded physicians.

  • 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.

  • 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).

Organ 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.

Organ 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.

Suggestions for Improvement
  • Would there be need for euthanasia if care were
    better organized?
  • Culture of Death?
  • Beneficence v. non-maleficence.
  • Do No Harm!

Palliative 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.

Palliative 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

Palliative 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'
  • reduced hospital costs,
  • a greater likelihood of death at home,
  • a higher level of patient and family satisfaction
    than does conventional care.

Palliative 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.

Palliative 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.

Expert Consultation
  • independence should be studied and reviewed
  • Who is the consultant?

Expert 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.

The patients attending physician
  • The patients attending physician, who supposedly
    knows the patients case better than any other
    expert, must be consulted, and all reasonable
    alternative treatments must be explored.

The 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.

Role of social workers
  • It must be ensured that the patients decision is
    not a result of familial and environmental
  • 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.

  • 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

Holistic care
  • Holistic care must be compassionate, addressing
    the physical, psychological, existential and
    spiritual aspects of the patients dying
  • All cases of physician-assisted suicide (PAS) and
    euthanasia should be scrutinized, examined,
    monitored, and studied carefully.

Thank you