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  • SWITZERLAND AND ASSISTED SUICIDE
    to be prosecuted whereas the physician would not Some members of the group opposed decriminalising euthanasia 10 Despite this report parliament voted not to go ahead with the proposed legislation and a change is unlikely in the near future The Swiss National Advisory Commission on Biomedical Ethics is debating these issues Its position cannot be predicted The physician s role The Swiss Academy of Medical Sciences states in its ethical recommendations that assisted suicide is not a part of a physician s activity 11 This statement is ambiguous It has usually been understood to mean that physicians should not assist suicide and was paraphrased in 2002 in a joint statement by the Swiss Medical Association and the Swiss Nurses Association 12 But the statement from the Swiss Academy of Medical Sciences has also been understood to place assisted suicide outside the purview of professional oversight and to refer physicians as citizens to the law This allows them like other citizens to altruistically assist suicide 13 In fact even if it is understood to discourage physicians from assisting suicide legally it leaves physicians with the same discretion as any citizen to altruistically assist suicide In practice many physicians oppose assisted suicide and euthanasia and hospitals have barred assisted suicide from their premises Some physicians however do assist suicides and some advocate the decriminalisation of euthanasia The arguments advanced are the same as in other countries Opponents argue that killing patients violates physicians professional integrity and endangers the doctor patient relationship 14 Proponents see assisted suicide and euthanasia as part of a caring response to intractable human suffering 15 In 2001 the Swiss parliament rejected a bill that would have barred physicians from assisting suicide The importance of palliative care is acknowledged Resources for palliative care in Switzerland are not yet available to all terminally ill patients This remains a strong argument against decriminalising euthanasia 16 No data are available on how well people believe the existing system is working in practice even though this is one of the key points in the controversy In another survey 73 of 90 physician members of the Swiss Association of Palliative Care opposed the legalisation of euthanasia However 19 stated that they would practice it if it became legal It is also an argument against assisted suicide and an important point in the public controversy Data on attitudes and practices Assisted suicide is a controversial topic in Switzerland but data on public attitudes towards assisted suicide and euthanasia are scarce According to one survey half of 2411 army conscripts were willing to shorten the life of a family member who suffered too much and who asked for euthanasia 17 In a 1999 survey of the Swiss public 82 of 1000 respondents agreed that a person suffering from an incurable disease and who is in intolerable physical and psychological suffering has the right to ask for death and to obtain help for this purpose Of these 68 considered that physicians should provide this help 37 considered that the family 22 that right to die societies 9 that nurses and 7 that religious representatives should be able to fulfil such requests Legislation to allow euthanasia was favoured by 71 of all respondents 18 No data are available on how well people believe the existing system is working in practice even though this is one of the key points in the controversy In another survey 73 of 90 physician members of the Swiss Association of Palliative Care opposed the legalisation of euthanasia However 19 stated that they would practice it if it became legal 19 This small support for euthanasia contrasts with the position of the European Association for Palliative Care 20 No survey has been conducted on the Swiss medical profession as a whole No validated statistics exist for assisted suicides in Switzerland These deaths are not differentiated from unassisted suicides in official records According to the president of one of the Swiss right to die societies around 1800 requests for assisted suicides are made each year Two thirds are rejected after screening Half of the remaining people die of other causes leaving about 300 suicides assisted by these societies annually This constitutes around 0 45 of deaths in Switzerland J Sobel personal communication 2002 21 Individuals outside these societies may assist additional suicides In comparison reported assisted suicide in Oregon represents 0 09 of deaths and other US data showed a rate of assisted suicide and euthanasia of 0 4 among terminally ill patients 22 23 The rate of assisted suicide in the Netherlands is 0 3 lower than the estimate for Switzerland 24 Conclusion Altruistic assisted suicide by non physicians is legal in Switzerland This has led to a unique situation It has separated issues that are sometimes conflated Whether assisted voluntary death should ever be allowed has been discussed without being exclusively linked to physicians Physicians have separately debated their appropriate role at the end of life They have a part to play in both debates Assisted suicide and euthanasia ask questions that cannot be answered from the perspective of medicine alone An incompatibility between assisting voluntary death and the professional ethos of physicians may mean that physicians should not assist death but it does not necessarily settle the argument of whether anyone ever should The controversy has remained intense Acceptance of assisted suicide seems to be growing but support for palliative care is growing also as end of life issues are kept in the public eye Further empirical analysis of this situation is important This debate could continue to yield insights into the issues around suffering at the end of life Note added in proof Recently the practice of one Zurich based right to die society that offers assisted suicide to non resident foreigners has attracted a great deal of media attention and concern This could eventually result in increased regulation but a radical departure from Switzerland s unique stance on this issue seems unlikely Acknowledgments We thank Ezekiel Emanuel Dan Brock Frank

    Original URL path: http://www.chninternational.com/switzerland_and_assisted_suicide.htm (2016-02-17)
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  • a tale of two cities
    charts They play a role in end of life care in family meetings Case History Family meeting A 50 yr old man with advanced lung cancer had chemotherapy which had failed He had a further course of another drug but then developed leukaemia He was confused in pain and wanted to go home The chest physician called a family meeting with the palliative care doctor The patient was in a side room with his wife two daughters brother mother a friend and granddaughter Others in the room included a social worker nurse and medical student The palliative care physician began with introductions and then explored the goals of care with the family as the patient was too distressed It was clear that some members of the family were still hoping for a miracle The physician then ascertained that the patient had always expressed a hope to be at home and identified which family members would be the key care providers He then outlined the role of the social worker in arranging hospice support at home He gave opportunities for the family to ask questions and they agreed that further treatments in hospital would be inappropriate and were grateful that their relative could come home An aim for the service is to achieve earlier referrals The palliative care team also provides continuity for patients in an environment where treating teams may change frequently and psychosocial care is fragmented They found that care plans and advance directives enhanced patient care A physician commented on the problem for doctors and patients in facing uncertainty When I first started in medicine uncertainty was my enemy The more I do palliative care I realize that uncertainty is my friend If anything can happen so hope can be maintained In Haborview Hospital the palliative care service has been set up by a nurse practitioner who runs the service single handed apart from some holiday cover As the service started with a research grant up to 40 of referrals come from intensive care Palliative care has remained hospital based because it is not funded and only large organizations can stand this loss of income In the intensive care setting the palliative care nurse helps in family meetings to discuss withdrawal of treatments and helping families come to terms with the situation This hospital has seven intensive care units and caters for some patients with severe stroke advanced cancer or other advanced disease with multi organ failure who would not be admitted to intensive care in the UK Part of the palliative care role was to bring humanity into the ICU enable them to focus more on the patient and less on the monitor The work of the specialist nurse is concerned with sudden illness crisis intervention establishing the goals of care The culture of the organization is such that It s almost a failure if they have to consult you for pain and symptom management Patients access to palliative care is controlled by treating physicians The service here has developed because the physicians and surgeons do not perceive the nurse as a threat Family meetings are held to establish goals of care we need to meet the family in advance otherwise we are throwing the family into a decision making role while they are still in crisis we need to know the person Sometimes these meetings were trying to deal with all the communication and emotional work in a single session There are cultural differences in patient expectations For some patients it is foreign to them not to know that what the physician says goes African Americans are often reluctant to access palliative care and hospice programs Historically there is a lack of trust in doctors perhaps exacerbated by the appalling Tuskegee Syphilis study which ran from 1932 and lasted forty years The study looked at the effects of untreated syphilis on African Americans None of the 399 participants consented and they were misled about the study When effective treatment for syphilis became available they were not given penicillin King PA Wolf LE 1998 Palliative care is sometimes requested because nurses become frustrated with over treatment There was some lack of understanding around the specialist skill set of palliative care Palliative care involvement may then appear critical of the treating team s care There was no admitting service for specialist palliative care and therefore no opportunity to manage the most complex palliative care problems In the Veterans Administration Hospital there is a multidisciplinary team which operates in the hospital and provides a system which is closer to the UK model of a hospital support team The management decided that every Veterans Administration hospital had to have a palliative care service but did not provide the extra funding The focus here was on inpatients and the hope was that palliative care could extend into out patient practice They appreciated that some patients need experienced specialist palliative care some of these need some grey hair and some experience In Portland the Veterans Medical Center has a multidisciplinary palliative care team with medical nursing psychology social work and psychiatric in put I attended a multidisciplinary team meeting and met highly skilled palliative care specialists There was a wide ranging discussion around medical social psychological and spiritual issues for each patient This team works with patients in the Veterans Center and has no outpatient or community remit Indeed families of the veterans are not covered by this Center In the Oregon Health Sciences University hospital there is both specialist medical palliative care and an ethicist in the team Ethics consults are a feature of hospitals in the USA and do not feature at all in the UK Palliative care in hospital was described by a doctor as SWAT team palliative care The Oregon team were involved in developing an innovative advance directive known as the Physicians Orders for Life Sustaining Treatment POLST Physician Orders for Life Sustaining Treatment POLST Advanced directives were originally developed as a means for people to have control over their end of life care when they were no longer able to make decisions themselves They originated as a response to the perceived excessive use of aggressive life prolonging treatments However from a patient s perspective their primary aim is to prepare for death and dying thus achieving a sense of control and relieving the burden on the family Over the past few years it has emerged that advance directives have many drawbacks which hinder their effectiveness in ensuring appropriate end of life care the completion rate is about 30 and they focus on treatment refusal rather than understanding the patient s values and goals They tend to be vague and may inhibit discussion on end of life planning The POLST form developed in Oregon is an attempt to improve end of life care by acting as a tool for communication about goals of care As well as acting as a basis for conversations between doctors patients and their families it is intended that it should follow the patient into any setting where care is provided It is an attempt to individualise planning but it does suffer the limitation of all tick box approaches It may confuse the patient with too many issues There should be frequent review of treatment plans as the disease progresses The POLST form is not a substitute for sensitive communication as it can be interpreted by people in different ways It is best seen as informative rather than binding since people can change their minds or the situation can change Perhaps what is needed is not just decisions on specific choices but rather to map a personal approach to dying Determining the place of care and limits of life sustaining treatment is an important way of relieving the burden on the family Planning needs to involve the family and friends and current approaches in bioethics neglects this social element of care It is the discussion around advance planning which is more important than the forms The forms however can act as a tool and give a framework for the discussions It is better to plan care at an earlier stage since it may be easier for patients to talk about end of life issues earlier when it s a bit abstract A sample form is included in Appendix B 4 2 2 The image of palliative care It is against the instincts of many teaching hospitals in the USA to consider palliative care as it is associated with impending death or even promoting death Even where there are resources for palliative care there is often resistance from the attending physicians to involve the palliative care team After one episode of the palliative care team s involvement a surgeon was quoted as saying You didn t do anything to make my life harder another said about the palliative care team I hate to have you guys involved but you know you were actually helpful There was agreement that psychosocial care was a neglected area in the hospital setting There is a circle of aggressive technological care with the doctors pushing and the patients asking for more treatment the picture is complicated because profit is involved Most of the advances in medicine result not in the cure of illness but in the prolongation of life in patients with chronic illness In such an environment palliative care can be an unwelcome presence because we are going in the opposite direction to everyone else in the hospital A physician felt that palliative care is often viewed as wimpier mushier not as rigorous 5 The American Health Care System I did not meet a single healthcare professional in Seattle or Portland who was enthusiastic about the American health care system our system here is lousy really bad its just appalling no political will to change it Whilst there are undoubtedly problems with our NHS the problems in the USA are so different that it is difficult to make direct comparisons of palliative care provision The United States spends twice as much on healthcare as other industrialsed countries in relation to gross domestic product There is a gap between rich and poor serious illness can result in poverty for those trying to meet their healthcare bills 60 of all credit card debt in the USA is related to health care payment Over 47 million Americans have no health care insurance cover Palliative care can only progress in the USA if it can compete in the market place Some hospital palliative care services have to demonstrate that their involvement in patient care saves money by earlier discharge from hospital In a capitated health care system we are challenged show us what you can do for us If we get them out of ICU earlier this is beneficial one reason why we have got into this area The problem is compounded by the fact that the culture demands continued rigorous treatment Nobody confronts end of life care until the last moment Difficulties can arise when the family wish to stop treatment but the physicians want to continue in the hope of a miracle Sometimes the palliative care team can be perceived by the primary treating team as advocating hastened death they appear to believe that by involving palliative care the patient s life will be shortened The evidence however indicates that good palliative care is linked to longer survival One consequence of the competitive market system of health care is that some patients are worried that they will be undertreated by being denied diagnostic tests or chemotherapy or life prolonging surgery This may be one factor to explain why so few African Americans have advance directives Historically as discussed earlier they have good reasons to distrust doctors 6 Education Educational initiatives in palliative care were carried out in both cities One doctor commented on the lack of training in communication skills in the undergraduate curriculum students are taught to go in and talk to the patient and get a code status whether the patient wants to be resuscitated that s what they think this talk is not What s important to you What do want to accomplish in the time What do you consider to be a good death or a bad death Have you seen people in situations which you don t want to be in Appropriate symptom control was always an educational challenge Low opioid prescribing continues to be an issue as you get new staff you are starting from zero Some felt that if the law was changed back in Oregon the benefits would continue in palliative care education A doctor in Seattle has also developed an innovative palliative care teaching module for undergraduates There is a paradox that these students may never have the chance to apply their training in a work setting However it is hoped that they may become agents for change The students learn when it becomes appropriate to have a discussion about the patient s goals for their end of life care As a rough guide they ask themselves Would I be surprised if this patient died in the next six months if the answer is No then they are taught that they should have a discussion along the lines of What might happen if things do not go well We spend seven years teaching medical students that patients are all the same We spend the rest of our careers learning that they are all different 7 Physician assisted suicide I had numerous descriptions of cases of PAS I include one that a doctor claimed went well and another which illustrates just how badly it can go wrong Case History A young man moved specifically here because Oregon had the law He had a strong belief in an after life He decided the day took the medication and died peacefully The hospice nurse knew the day but was not involved She came to the house after his death and supported the family Case History A patient with a cancer had a friend who was a doctor This friend told him that it was going to be a painful way to die and advised him to take advantage of the PAS law The hospice staff felt he was not ready to die and were concerned that he may have bypassed some of the legal hoops The family were not happy and everybody involved was uneasy After taking the lethal prescription the patient didn t die quickly The family were upset why hasn t he died The wife said she had to leave she could not cope with the situation The volunteers from a pro PAS organization found two men who knew nothing about nursing care to sit with the patient until he died the next morning The wife became profoundly depressed and attempted to commit suicide herself Physician assisted suicide PAS was sometimes referred to as hastened death Physician assisted suicide is a misnomer because it is not just the physician who is involved but family pharmacists and nurses There were different opinions amongst physicians some felt that the lines between terminal sedation PAS and euthanasia were blurred I am not an advocate for hastened death but I have done it I can make myself feel better but it is often very grey when you look at it with a clear eye Death with Dignity legislation was first raised in Washington State and defeated largely because the physicians took an active stance against it In Washington state there was much resistance to PAS they don t want to do it don t want to abandon their patient it goes against the grain of how people are trained There is a fundamental lack of continuity of care so they can t claim to know the patient that well Its morally ambiguous Euthanasia will never be sanctioned in the USA but PAS could be It was felt in Seattle that in Oregon families receive more psychosocial support because the law exists but that in Washington state there is no support for families or patients seeking a hastened death because it is illegal Others think that it is possible that harms can result from not having a choice for PAS You are not looking at the harm which results when PAS is not done if it is illegal it is not going to stop the practice None of the arguments against PAS convince me Make it harder that s OK look at the harms to those who seek it and can t have it compared to the wider harms to society An ethicist felt that we should keep the option for PAS on the table We want to manage death on their terms and in the vast majority of case palliative care does that but we need to recognize that there are some patients we can t help The option to have PAS was widely perceived as a safety net its an insurance policy I have a way out I need to be strong so I can fight and be strong I don t think that these people want to die they want an insurance Is it better it happens in secret You guys are light years ahead of us I think it should be rare I want to prevent a violent suicide The urge to prevent violent suicide was graphically illustrated by a sad case Horrifying violent suicides discovering a husband s headless body in the garden the legacy left behind for the family is horrible Nurses vary in their views on PAS about a third are opposed and about 10 would seek not to be involved with that patient in any capacity Doctors attend about a third of the time mainly to assess competency some do not give the medication until the patient is ready to take it The patient is unwilling for the doctor to implement PAS they wish to carry it out for themselves sometimes they do not wish the doctor to be present Hospitals in Oregon do not permit PAS on their premises However there is no problem for a patient in finding a doctor who will carry out PAS Most commonly their own doctor will not agree but refers the patient to a hospice program The hospice doctors do not sign lethal prescriptions but may refer the patient to another doctor who is willing to do so or patients usually contact the organization Compassion Choices Oregon which has a list of doctors who are willing to carry out PAS This organization strongly supports the legalization of PAS and provides information and advice to those interested in PAS They also have volunteers who may be with the patient when they take the lethal medication This organization is involved in about 75 of the cases of PAS in Oregon Compassion Choices Oregon maintain that PAS deaths are not suicide but hastened death The death certificate in a case of PAS certifies natural causes as the cause of death and does not mention PAS A Compassion Choices representative emphasized that he felt even if no one used the law it would still be worth its weight in gold for the comfort it provides He felt that patients are not requesting PAS because they are suffering but because they are choosing not to have the experience of dying from their underlying disease For this small group who choose to take the medicine I am not here to judge whether it s right or wrong I make sure the option is available In one hospice program they have had 28 cases of PAS since the legislation was in force In 23 of the cases same doctor was involved He is known as a strong advocate for patient choice and does offer all the alternatives Only a few doctors participate perhaps because a significant proportion of Oregonians do not support PAS There can be problems in leaving the lethal medication at home In one case where there was doubt as to whether the patient was competent when he eventually took the medication and it may have been administered by the family The question of administration was a delicate one a patient even had a PEG feeding tube inserted solely to allow him to have PAS To qualify for the Oregon PAS legislation the patient must be a resident in the State Any citizen of the USA can be a resident of a state if they declare that it is their intent to reside in that state permanently In Seattle a physician expressed his view If you offer good quality palliative care PAS is very rarely an issue Offering PAS in absence of good palliative care is a travesty 8 The request for PAS In America getting old is sin enough dying is unspeakable A Physician The request for PAS is an opportunity to explore the reasons for the request Patients often receive care from a number of doctors who may not communicate with each other I had a patient with lung cancer she went to another physician and got a prescription I found out later from the family that she had done PAS Only about 30 people in Oregon use PAS each year of the 35 000 deaths per annum This tiny group have been studied extensively and contrary to earlier assumptions they are not suffering terribly they are not in pain and nor are they depressed This group of people have always had a strong need for control throughout their lives They simply want to be able to choose the time of their death and prefer to avoid a violent suicide Research in Oregon suggests that these hyper independent people often have a history of childhood deprivation and have had to learn to survive on their own They dislike losing control and having to depend on others so palliative care has no appeal for them They may not even seek support from their family who may wish to care for their loved one Paradoxically doctors also share some of these characteristics of wanting to be in control It is a measure of their determination that they go through so much work to achieve PAS while they are ill One woman who was contemplating PAS went to buy apple sauce to mix with the tablets to make them more palatable Her husband saw her in the supermarket studying the label on the jar to see if there were any additives or colourings Families may be placed in an ambiguous position and some have the fear am I encouraging him to die by supporting his decision Family members might not agree with PAS but feel that out of respect for my mother I go along with it One perceived positive element of the PAS request is that there is no longer room for denial in these families once the request is made the elephant is not in the room Some felt that the size of the problem was too small to justify creating a national policy to cater for this tiny group of people who need control There is a whole spectrum of involvement even among those opposed from being out of the room when it happened to being there to support the patient while they took the medication to mixing the tablets in a liquid to make it palatable to helping to administer the lethal prescription If family members are helping we are not hearing about it It s possible to get a lethal prescription without the hospice knowing about it they wouldn t want to offend the hospice nurse Nurses gave differing descriptions of PAS deaths some said it was a pretty death with the majority of family members thinking it was wonderful Others described the patient screening out family members who would object A nurse spoke of supporting a son mixing the medicine for his mother and after she took it he was sobbing uncontrollably Of the patients who first request PAS only 1 in 10 get as far as getting the medication and of those only about half take it So many more talk about PAS than do It There is a strong feeling that they have an out Hospice staff were not entirely comfortable with their position we are all glad when they don t do it At one meeting which I attended there was a bleak pause as a nurse excused herself to attend a patient whom she had never met who was going to commit suicide at 2 pm Many patients who initially ask about PAS change their mind If you come right at PAS they kind of hang on to it more but if you nick at the edges from hospice help to make them feel in control and show how I respect you as a person then many don t go down that route 90 go for hospice The most common response from physicians to a request for PAS is referral to hospice Hospice program staff felt that pain control was not an issue for those seeking PAS They don t want to take the chance of a poor quality of life Whilst many patients gain comfort from the safety net of the legislation permitting PAS others can be traumatized by insensitive communication Case History One patient with motor neurone disease ALS was given the diagnosis and at the same time was informed by the doctor of the availability of PAS You have ALS this is awful you should consider PAS The patient felt devastated Most hospice staff felt that it was wrong to deny patients who had chosen PAS the same emotional care as any other patients One comment was that it was difficult when it first became law but was more acceptable now A fter the first year or two it became normal it wasn t a big deal Hospice teams identified which patients had requested PAS and regularly reviewed whether they had changed their minds If a team member did not support PAS they could opt out of the care of the patient One team said they had never seen bad deaths from PAS and had only one patient that took 24 hours to die Some patients practice to make sure that they can swallow the 200ml of liquid necessary to dissolve the pills Some felt that it was not a just law because it was not available for those who could not swallow A patient with ALS motor neurone disease may have to suffer for years and does not have this choice whereas a cancer patient who is going to be dead in six months anyway and may not be suffering does have this choice A patient may have no suffering but once they have their six month prognosis they can start the process for PAS The patient can come to the hospice as part of the process and with the sole intention of committing suicide wait the required 15 days then take the lethal medication It is assumed that these patients are not clinically depressed and there is no psychiatric assessment One ethicist was concerned that the harms of closet PAS outweigh the hypothetical harms of legalized PAS There is an urge to prevent violent suicide either by using a car or a gun It was hard to know whether more palliative care would have made a difference There was concern that by keeping PAS illegal that it would inhibit communication around death and dying However in the UK palliative care specialists feel protected by the legislation which permits them to raise questions about death and dying without fear that the patient might think they are suggesting PAS as an option Research has found that patients who carried out PAS could be divided into three groups according to how far their disease had progressed 1 Those who were clearly dying and were within days of death It appears that the issue for them is one of control These cases were not so distressing to the researcher 2 A group who probably had about few weeks to live They had no unfinished business they were just worn out They just felt that they were not dying fast enough 3 A small group who hastened their death despite having the potential to survive much longer The researcher describes her ambivalent feelings about this group When we started to work back it all became more uncomfortable and felt like it was rather like a preemptive strike very hard its hard to say that you know better than them all three of them had personality twists they had become self reliant narcissistic and manipulated everyone around them it was all about them do you say they are incompetent areas of sympathy in their story these are unconventional people what do you do They had carefully thought through what would happen to them we have had a full life and done the things we want to do the things ahead I don t want I don t know why I have to because you tell me I have to go through it The effect on family community it s not easy to challenge people who are dying they don t consider other people In Seattle a nurse commented We do see people who request PAS or hastened death The discussion follows to see if we can meet some underlying unmet need then we may discuss palliative sedation if that seem s appropriate They said that palliative sedation was rarely necessary 9 Research I talked with members of two research groups one in Seattle and the other in Portland It was invaluable to be able to discuss their research and explore their own feelings about PAS and end of life care Seattle group PAS illegal Most previous research on clinical responses to PAS requests have used data obtained from clinicians The Seattle group studied 35 patients who were seriously considering PAS 12 prospectively and 23 retrospectively Three themes emerged that were valued by patients and their families Openness to discussions about PAS Clinicians expertise in dealing with dying process Maintenance of a therapeutic relationship even when the clinician and patient disagree about PAS It is interesting that this group also found that PAS requests may not persist and that the most prominent concerns were about non physical aspects of dying loss of control and dignity Yet doctors feel least comfortable when addressing existential suffering Clinicians who deal obliquely with PAS requests may miss the chance to fully evaluate and understand the issues underling the request Patients were looking for more than a prescription they sought a guide through the dying process They suggest that clinicians should respond to a request for PAS by using the guidelines Address the PAS request explicitly and openly Ask about what kind of death the patient would like to have After understanding the patient s wishes and expectations offer to discuss how dying could be managed Check the patient s perception What are you taking away from our talk today The process of building a therapeutic relationship is more important than providing a lethal prescription Monitor yourself for over or under involvement in the doctor patient relationship Some researchers looked at the skills required by physicians in providing end of life care they suggest 12 domains of skills Curtis JR et al 2001 Accessibility Continuity Team co ordination Communication Communication with patients Patient education Inclusion recognition of family Competence including knowing when to stop Pain Symptom management Emotional support Personalisation Attention to patient values Respect and humility Support of patient decision making within these domains Family members may have different moral values to those of the patient requesting PAS Families have multiple needs but little preparation is made for their role in the care Where hastened death is illegal there are even fewer resources to support families in their role as witness to and sometimes facilitators of a hastened death Patients and families have the added tasks of negotiating with physicians for prescriptions for lethal medications They also were concerned to minimize the risk of investigating the death They found in their series of 35 patients that 6 families encountered problems related to the medication during the dying process In 2 cases the patient took over 11 hours to die and in 4 cases the patient woke up Most families however were able to face issues of dying and make plans for the event but lack of professional support left them unprepared for adverse endings They often felt responsible if the patient woke up and those families who experienced complications had difficulty adjusting to their loss They also had worries about legal consequences The main motivating factors for an interest in hastened death were illness related experiences issues of loss of sense of self and control and fears of the future No patients met the criteria for a major depression episode EVig et al The results from this study show that just as in Oregon it is the patients who are keen to be control who seek PAS Lack of palliative care was not an issue for them Portland Group PAS Legal Ganzini and her team have been concerned with exploring the views of healthcare professionals on PAS Psychiatrists in Oregon were divided in their belief about the ethical permissibility of PAS Only 6 felt very confident that in a single evaluation they could adequately assess whether a psychiatric disorder was impairing the judgment of a patient requesting PAS Ganzini L et al 1995 Only a minority of Oregon Physicians were willing to provide lethal prescriptions 73 out of 2094 respondents Ganzini et al 2001 Oregon physicians described patients requesting PAS as having strong and vivid personalities characterized by determination and inflexibility Ganzini L et al 2003 Most hospice social workers and nurses in Oregon do not believe that assisted suicide and hospice enrolment are mutually exclusive alternatives 48 of the Nurses supported PAS and 72 of social workers supported PAS Miller LL et al 2004 In another study 1 in 10 cancer patients expressed a serious interest in obtaining a lethal prescription at the initial evaluation though the number of patients maintaining interest in PAS varied Fewer than half of these patients discussed the issue with their oncologist Of the 161 participants in the study only two ultimately made an explicit request for PAS one of whom never indicated interest in PAS on any study assessment Ganzini L et al 2006 This study was the first to measure satisfaction with medical care and found that dissatisfaction with care was associated with interest in PAS Exploring specific causes of this dissatisfactions would be key to developing interventions Ganzini L et al 2006 The researchers found that many patients with serious interest in PAS do not discuss this with their doctors or any other person Clinicians in Oregon have been advised not to initiate discussions about PAS as there are concerns that patients may misinterpret enquires believing the physician is promoting PAS Ganzini L et al 2006 It is difficult for the physician to explore the patients deepest feelings if he she cannot ask whether the patient has contemplated suicide In contrast the current UK law is helpful in that it gives doctors the freedom to raise these issues without any fear that that they are misunderstood as veiled suggestions of PAS A reluctance to discuss these issues may leave the patient struggling in isolation Expressing an interest in PAS does not seem to predict actual requests but it does indicate psychosocial distress Ganzini L et al 2006 10 Ethical Considerations Those arguing for PAS justify their view by suggesting that it offers greater autonomy for the individual who they feel has a right to choose the time and manner of their death The American legal system in Oregon values and exalts individual autonomy the right to choose PAS places a responsibility of physicians to help A physician said Americans are drunk on autonomy another ethicist

    Original URL path: http://www.chninternational.com/a_tale_of_two_cities.htm (2016-02-17)
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  • Hospices
    research in clinical care for the terminally ill that depart from traditional notions of care The modern methods depend increasingly on harmful drugs which the patient may not need or which may be inappropriate Less harmful treatments could be given which do not increase drowsiness and risk the patient becoming unconscious Hospices were originally places where the dying were cared for until death from illness progression The nurses and staff were imbued with Christian values of caring for the dying The patient was made as comfortable as possible and their spiritual needs were attended to There was no question of hospices being associated with hastening death This is the image that most people still have of hospices The suggestion that maltreatment and the administration of drugs that hasten death are happening in hospices is difficult for people to accept Terminal restlessness is one area which should not be treated by sedation without due thought It is sad that some hospice staff fail to consider the causes of terminal restlessness in an individual patient but use drugs to treat this condition by sedating the patient The comfort of the dying patient should be attended to and inquiries made concerning any physical symptoms such as constipation or urinary problems The patient may be worried or suffering emotional distress All too often sedation is used where care would be appropriate such as repositioning the patient moving their legs or transferring the patient from the bed to the chair The environment where the dying patient is cared for should be made as soothing and calm as possible and he or she should be surrounded by familiar items The problem in hospices and also in hospitals is that patients may be sedated for the convenience of nurses rather than any clinical need If patients are anxious a thorough consultation should be made to inquire into the causes and whether drugs are needed If the patient suffers with nausea anti emetic drugs without a sedative should be used Patients should not be drugged into unconsciousness rendering them incapable of stating their wishes handling their own affairs and speaking with their loved ones Drugs should be kept to a minimum in elderly patients and those with compromised renal and hepatic function It is also of concern that hospices make assumptions concerning the withdrawal of nutrition and hydration even though a patient might benefit from these It is understood that a stage is reached in the terminally ill when feeding becomes burdensome and the appetite decreases Some patients may no longer be able to swallow However a patient who is not actively dying might benefit from continued nutrition with soft food and liquid food Moreover meal times can be psychologically good for the patient even if the patient cannot eat much Meals provide a good social occasion for the sick Rather than giving up on patients food could be offered and patients tempted with food that they like If they derive pleasure from an item of food that

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  • CHN Digest Online: January 16, 1996 Vol.1 No.4
    Deane PA News January 16 1996 The British House of Lords released their full report in 1994 concluding that We recommend that there should be no change in the law to permit euthanasia Rejection of euthanasia as an option for the individual entails a compelling social responsibility to care adequately for those who are elderly dying or disabled Report of The Select Committee on Medical Ethics House of Lords 1994 Vol I paragraph 262 p 54 For more information on euthanasia and international opposition to legalising euthanasia see Physician Assisted Death Is It Right For Canada A 56 page report submitted by the Compassionate Healthcare Network to The Senate Special Committee On Euthanasia and Assisted Suicide August 1994 2 REGARDING THE RIGHT TO REFUSE MEDICAL TREATMENT THE RIGHT TO SELF DETERMINATION Commentary by Cheryl Eckstein CHN Itai Arad a former Israeli fighter pilot asked an Israeli court to bar doctors from connecting him to life support and allow him to die with dignity Arad has Amyotrophic Lateral Sclerosis ALS or Lou Gehrig s Disease but does not yet need life support to help him breath Euthanasia is illegal in Israel a society deeply rooted in the Jewish notion of the sanctity of life says an Associate Press release The report goes on to say But Israeli courts have allowed doctors some discretion in how they treat terminally ill patients Associated Press Jerusalem 31 12 95 Reporting that euthanasia is illegal in Israel in this story muddied the issue at hand and mislead some readers to falsely conclude the request to die with dignity was a request to die by euthanasia In fact Arad s request is to 1 die in his own home and 2 not be forced to be put on a respirator if and when he is unable to breath on his own Keeping to the facts would avoid possible misinterpretation If Itai Arad was a resident of Canada he would not have had to bring his request before a court In 1935 a law was established in Canada that states patients have the right to refuse life sustaining medical treatment This can also be classified as the patient having the right to self determination The patient is allowed to die without medical intervention Even if the treatment outweighs the disadvantages the physician must respect the wishes of a patient who possesses decision making capacity to forego treatment Thus every Canadian has the right to refuse medical treatment The primary cause of death is the underlying disease The Nancy B case is an example of a patient wanting treatment that has already begun to be terminated In Nancy B v Hotel Dieu De Quebec Quebec Superior Court Dufour j 13 86 D L R 4th January 6 1992 Held the plaintiff was entitled to the injunction sought Permission should be given to her physician to cease treatment with the respirator at a time chosen by the plaintiff The physician was entitled to the assistance of the hospital Id

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  • Euthanasia in UK
    html Doctors step into right to life row Doctors have stepped into a right to life row following the suggestion some hospital patients should be allowed to die because it costs so much to keep them alive The Daily Mail reported that leaked Government papers suggest that they should be denied food and liquid if they fall into a coma or are too ill to speak for themselves The Department of Health has refused to comment A spokeswoman said I cannot comment on the Daily Mail story I can tell you it is a leaked document We are not saying anything further However the British Medical Association said it would be quite wrong to let financial considerations affect decisions on when to withdraw food and water A spokeswoman for the BMA said It would be quite wrong to make a life or death decision based on the cost of treatment She also criticised a move by the Department to seek clarification on a right to life ruling saying it was already clear High Court judges ruled last July that patients if competent should determine what is in their own best interests in choosing whether to have food and water They also decided that the courts would have the final say in cases of people who cannot make a decision because they are unconscious or incompetent or have not given prior indication as to their wishes Health Minister Rosie Winterton said It is not true that we are refuting the judgment on artificial nutrition and hydration made last July But we felt that the judgment went beyond artificial nutrition and hydration and has left it open ended We are therefore seeking clarification otherwise doctors would have to return to court every time a case like this arose But the BMA spokeswoman said The law is clear People have the right to die if that is what they wish but even then doctors could persuade them to have some treatment to relieve symptoms Click here CBHD Euthanasia Who Needs It Sharon A Falkenheimer http www cbhd org resources endoflife falkenheimer 2005 01 31 htm Death on doctor s orders Euthanasia campaigners are hailing Oregon s right to die law as a blueprint for Britain Jo Revill Sunday December 5 2004 The Observer When Karen Yanoch was ready 18 of her closest friends and relatives came to sit around her bedside at her home in Eugene Oregon Each of them had received a formal invitation to be with her in her final moments Yanoch who was terminally ill with liver cancer had decided to end her life by drinking a bitter solution of a lethal barbiturate She took several small sips and then a final big gulp Three minutes later lying in her bed wearing her favourite striped socks she told those around her I think I m going to sleep now as she lapsed into a coma before dying shortly afterwards Yanoch s death last April was hard for her friends to take but they understood why she had opted to depart in her own way at a time of her choosing She could do so only because the state where she lived had a law the Death with Dignity Act which allows what is known as physician assisted suicide This week an influential committee of the House of Lords will fly to Oregon to study how this law is working At present the committee is scrutinising a private members bill which would legalise assisted deaths for the terminally ill The crossbench peer Joel Joffe a retired human rights lawyer is hoping to steer the bill through the Lords If he succeeds it will be debated by MPs who are far less convinced of the case for voluntary euthanasia It has already sparked off fierce debate about how society can best help the dying Joffe s proposals centre around the concept that voluntary euthanasia would be made available to patients in unbearable pain who have less than six months to live They would have to undergo psychiatric and medical examinations and there would be a cooling off period to allow them to change their minds Tory peers vehemently oppose the bill which attracted 100 000 submissions of evidence during its consultation process which ended earlier this year The bill is completely at odds with the present British law which makes it a criminal offence punishable by imprisonment to assist anyone who tries to kill themselves But the peers have chosen to go to Oregon to look at how doctors there administer the scheme and the kind of ethical dilemmas it raises On Friday they will meet Dr Nick Gideonse a family doctor in Oregon s largest city Portland The softly spoken Gideonse has helped five patients die using the Death with Dignity Act Every case has its own complexities and there are always mixed feelings about the process he said But what I m increasingly aware of is that the law as it s designed works well It gives people an open avenue of communication about the things they care about such as the ideas they have about what dying might be like as well as for the much smaller numbers who use the law The figures on this back him up Since the Act was introduced six years ago nearly 180 people have been helped to commit suicide but that is only around 1 per cent of the number who have requested information about it The latest figures show that most of the patients like Yanoch were terminally ill with cancer Around 20 per cent had motor neurone disease Their median age at the time of death was 70 much older than some critics of the act had predicted They have tended to be college graduates better educated than the majority of the population The doctor says the people who use the law tend to have a long history of independence and self reliance It takes courage and quite a lot of strong will to do this particularly when these people are really quite ill and have low reserves of energy Gideonse said The Oregon law is framed to allow adults with terminal diseases who are likely to die within six months to obtain lethal doses of drugs from their doctors They have to talk through the process with the doctor and agree to have a full interview with a second physician to make sure that they are mentally competent There is then a 15 day cooling off period when they can think about their decision If they decide to go ahead after that they have to see another doctor before approval is given But the Oregon law has provoked controversy in others parts of the United States It has been fiercely opposed by President George Bush whose stance has the backing of conservative Christian groups The American Appeal Court recently upheld Oregon s Act ruling that the Attorney General John Ashcroft had overstepped his authority by trying to punish doctors in the state who had prescribed suicide drugs And while there is still strong opposition around the country to laws such as Oregon s support within the state has grown over the years Its voters have approved the Act in two separate referendums and even some former opponents say the widespread abuses forecast initially have not taken place Yet there remain many across the States who detest it Physicians For Compassionate Care a group which is campaigning for repeal of the law argues there have been cases of depressed and mentally ill patients being helped to die a claim strongly denied by state officials The group also says more persuasively that good palliative care can do an enormous amount to alleviate pain but that often this avenue isn t open to patients In Britain the arguments about euthanasia were brought into the open last week A High Court judge cleared the way for a husband to help his wife referred to only as Mrs Z as her anonymity is protected by a court ruling travel to Switzerland so she could be helped to die The couple had been stopped from going to Zurich by the local authority which provides care for her Mrs Z could not go by herself as she suffers from an incurable brain disease but her husband had agreed to help her to get to Dignitas an organisation which helps people to commit suicide Last Wednesday immediately after the court ruling the woman flew to Zurich where she took a lethal dose of barbiturates in a flat accompanied by a doctor nurses and a lawyer The British court had ruled that the law should not interfere with the rights of the wife to die The case appears to weaken the barriers that prevent assisted suicide in English law under which it is a criminal offence punishable by up to 14 years in jail Whether more British people will now travel to Switzerland to end their lives remains to be seen but euthanasia has again started to become a real public concern Health staff have shifted their positions on this issue The Royal College of Nursing has moved from being steadfastly against assisted dying to a stance of neutrality In 1996 54 per cent of 1 000 doctors polled favoured legalising it in some circumstances Three per cent of GPs had helped terminally ill patients to die But one of the big surprises of the Oregon law is that the patients who choose their own time to die are not so much depressed as determined Linda Ganzini a psychiatry professor at Oregon Health Sciences University led a survey of 35 doctors who had been asked for suicide drugs and found them describing the patients as feisty and unwavering When patients gave their reasons for seeking assisted suicide their greatest concern appeared not to be fear of pain but fear of losing their autonomy This was cited by 87 per cent of those who went on to take their lives with the drugs Only 22 per cent gave their reason as fear of inadequate pain control The standard version of care says in effect We re going to take care of you said Ganzini But for these people the real problem is just that other people taking care of you Related links www prolife org uk The mainly anti abortion party also takes a robust line against voluntary euthanasia Hospitals in euthanasia row By Lech Mintowt czyz Evening Standard 13 December 2004 Four London hospitals are allowing elderly patients to request that they be allowed to die it emerged today Doctors are allowed to mark down any request by patients that they be allowed to die if they become critically ill Hospital managers have told them they can follow any such instruction should the circumstances arise A spokesman for the Hammersmith Hospitals Trust which has launched the initiative said doctors did not ask patients for their views and only marked their notes should they make a specific demand Patients at each of the trust s four hospitals Hammersmith Charing Cross Ravenscourt Park and Queen Charlotte s and Chelsea are understood to be affected The spokesman denied the policy amounted to allowing patients to make a living will but reports in today s Daily Mail drew savage criticism from pro life campaign groups Phyllis Bowman of Right to Life said You tick the box and you are ticking your life away Elderly people are very easy to coerce especially when they are on their own confused and sick in a hospital bed Julia Quenzler of the SOSNHS campaign group added If ever the elderly and vulnerable needed confirmation that they are considered expendable this is it Lib Dem health spokesman Paul Burstow said If this is what Hammersmith are doing they need to rethink At no point should it be acceptable for the purpose of a doctor to be to hasten someone s death There are far too many assumptions made about a person s ability to recover and enjoy life on the basis of their birth date The controversy comes as MPs prepare for a row over the issue of living wills during tomorrow s debate on the Government s Mental Capacity Bill More than 100 MPs from both sides of the House are said to oppose the Bill which critics call a charter for euthanasia The Bill proposes to give legal backing to living wills in which individuals specify how they would be treated should they become incapacitated and unable to communicate As treatment includes provision of nutrition and water by tube this could involve allowing death by starvation or dehydration Over the weekend medical expert Baroness Warnock fuelled controversy by declaring she did not want to be a burden on her family The 80 year old peer said In other contexts sacrificing oneself for one s family would be considered good I don t see what is so horrible about not wanting to be an increasing nuisance Age Concern branded her stance outrageous Source http www thisislondon co uk news articles 15284596 source Evening 20Standard An attempt at euthanasia Court documents say caregiver tried to kill her patient Originally published Sunday December 19 2004 By Sandra Wisecaver Times News correspondent GOODING A Hagerman woman who court documents paint as a caregiver with a twisted sense of divinity has been charged with attempted first degree murder Police say Kathleen Marie Allen 47 tried to kill the 65 year old man in her care with a potentially lethal dose of morphine Court documents related to the case describe a chilling attempt at euthanasia that came to a head on Feb 25 When police responded to Allen s home at 340 Orchard St in Hagerman that night they found Allen s patient Jack Duane Reed comatose He was transported to the hospital for medical attention and to be taken out of Allen s care The investigation that ensued would eventually lead to Allen s arrest seven months later Christine Funk a woman related to Reed called police the night of Feb 25 because Allen was out of control yelling and telling Reed to die court documents say Funk had been concerned about the care being provided to Reed Three days earlier Allen telephoned Funk to say Reed was dying and she was making funeral arrangements Funk told police And on Feb 24 Allen told Funk she had signed a do not resuscitate order for Reed that Funk objected to the court documents say Funk an employee with the Gooding County Ambulance District told police she went to Allen s residence on Feb 24 Funk said Reed s pupils were dilated to the point where there was no visible color to his eyes At about that time the court documents say Allen started yelling that she was God and it was time for Jack to die Others corroborate events Gooding County Prosecutor Philip A Brown filed a criminal complaint against Allen in 5th Judicial District Court on Nov 1 She s also been charged with grand theft by embezzlement of currency and property in connection with the sale of some of Reed s antique guns and the tampering of his bank account Allen was released from the Gooding County Jail on Nov 3 A preliminary hearing in her case has been set for Feb 17 Reed who has since turned 66 remains in Funk s care today and is doing fine Funk recently told The Times News Others interviewed by Hagerman police and Idaho State Police corroborated the accusations against Allen court documents indicate Madlyn Shepherd a Hospice employee who cared for Reed in August of 2003 told investigators that Reed had some medical problems due to his age but seemed in good health before going under Allen s care Shepherd was again assigned through Hospice to assist in Reed s care this past January at the Allen home in Hagerman At that time Shepherd said Reed could walk and talk court documents say But Reed soon developed breathing problems and Shepherd requested blood tests to determine if he was getting the proper medication Those tests showed a very low level of lithium which had been prescribed for Reed court documents say If properly medicated Reed s lithium level should have been higher Shepherd also said she learned that Allen had contacted Reed s doctor and demanded he prescribe Roxanol a form of liquid morphine Certified Nurses Assistant Merelda Okelberry another Hospice employee gave police another disturbing description of Allen s method of care On Feb 25 Okelberry said Allen came to her and requested she give Reed enough Roxanol to knock him out When Okelberry questioned Allen about her intentions Allen replied You might as well just kill him and get it over with It s not fair God wants him dead and he s fighting it court documents say During her interview with investigators Okelberry further quoted Allen as saying Give him the whole thing Let s get this over with Jack is supposed to die The case of embezzlement In an April 7 interview at the Funk home Reed was able to walk and talk again According to court documents Allen told Shepherd she was caring for Reed in her home free of charge But Allen told authorities that Reed had agreed to pay her and Phil Dawson Reed s ex husband 2 500 per month for his needs care and food Allen said Reed s medical insurance covered medication Court documents say that in August 2003 Reed granted Dawson and Allen power of attorney and access to his bank account Bank records show Reed received 2 971 70 per month and that Reed had in excess of 3 000 in August 2003 On Feb 24 a transfer of 1 419 58 to the Kathleen Allen Easy Street Assisted Living account left the Reed account with a 0 balance Firearms from Reed s antique gun collection also were

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  • Mental Incapacity Bill Dr P J Ho
    There is a clear intention of the BMA to support decisions to withdraw hydration and nutrition from patients who are not in PVS without the sanction of the court 21 1 The BMA can see no reason to differentiate between decisions for patients in PVS and those for patients with other serious conditions where artificial nutrition and hydration is not considered to be a benefit which are currently governed by established practice without the need for legal review It is perhaps not surprising that the BMA also recognizes a right of conscientious objection to those such as myself who would object to causing a patient to die of dehydration 24 1 Where a member of the health care team has a conscientious objection to withholding or withdrawing life prolonging treatment he or she should wherever possible be permitted to hand over care of the patient to a colleague This is a best practice which may also now be necessitated by the guarantee of freedom of conscience in Article 9 of the European Convention It is also not surprising that the BMA recognizes the strain that such policies would place on staff and the need for support 26 1 Although not responsible for making the decision to withhold or withdraw treatment those close to the patient are often left with feelings of guilt and anxiety in addition to their bereavement It is important that the family are supported both before and after the decision has been made to withdraw or withhold life prolonging treatment 26 2 The emotional and psychological burden on staff involved in the withdrawing and withholding of life prolonging treatment should be recognized and adequate support mechanisms need to be available and easily accessible before during and after the decisions have been made If the BMA recognizes such stresses amongst staff making these decisions how much more stressful would it be for Attorneys or court appointed deputies if they were making these life and death decisions as proposed by the Mental Incapacity Bill The BMA recognizes that Where the patient has died following a decision to withhold or withdraw life prolonging treatment however the usual bereavement may be exacerbated by feelings of guilt or anxiety about whether the right decision was made and about the family s role in that decision GMC G UIDANCE ON W ITHHOLDING AND W ITHDRAWING T REATMENT The GMC Guidance is an improvement on that of the BMA but it still acknowledges that hydration and nutrition might be withdrawn from patients who are not dying in paragraphs 38 and 81 Paragraph 38 Always consult a clinician with relevant experience in cases where you are considering withholding or withdrawing artificial nutrition or hydration from a patient who is not imminently dying although in a very serious condition and whose views cannot be determined see paragraph 81 below Para 81 Where death is not imminent it usually will be appropriate to provide artificial nutrition or hydration However circumstances may arise where you judge that a patient s condition is so severe and the prognosis so poor that providing artificial nutrition or hydration may cause suffering or be too burdensome in relation to the possible benefits In the July minutes of the GMC Council which can be seen on the GMC website it was acknowledged that there are issues relating to the legality and ethical standing of the GMC Guidance on Withholding and Withdrawing Treatment Our guidance was prepared with the assistance of the Official Solicitor and a professor of medical law It was the product of lengthy and detailed consultation and careful consideration of statute and common law No significant concerns about compatibility with ECHR were identified during the drafting or consultation process We did not therefore seek Counsel s opinion on the guidance However the implications of the ECHR are developing as cases come to court as the result of the Human Rights Act 1998 In the light of these developments and the opinion from Richard Gordon QC now in the House of Lords library we are now considering whether to seek an opinion from leading Counsel to provide further advice on the human rights implications and an authoritative opinion to which we may be able to refer if further public comments are made about the lawfulness of our guidance In his advice Richard Gordon argues that The GMC Guidance envisages situations in which although a patient s death is not imminent life prolonging treatment my be withdrawn There is no suggestion in the guidance that this may violate Articles 6 2 3 or 8 see above Further even the existing domestic ECHR case law does not go so far The Guidance is therefore materially misleading I consider that the provision of hydration in such cases is likely to fall within the scope of the State s positive obligations under Article 2 ECHR Failure even to advise clinicians of the important of compliance with the principles set out in existing case law and with the separate obligations under Articles 6 3 and 8 ECHR renders in my opinion this Guidance in this respect unlawful He recognises however that even the GMC at least doubts the legality of its own advice Note for example paragraph 17 4 of that Guidance which is ostensibly in direct conflict with paragraphs 38 and 81 of the GMC Guidance providing materially as it does that Except where the patient s imminent death is inevitable a decision to withhold or withdraw all treatment is likely to be inappropriate and potentially unlawful C ONCLUSION The Mental Incapacity Bill would permit an extension of the House of Lords decision in Bland 1993 to patients who are not in PVS and to whom a duty of care remains Such decisions would not be subject to judicial review but rather could be made by an attorney or court appointed deputy The state would be failing in its duty to positively safeguard life under Article 2 of the ECHR Deliberate dehydration of a conscious patient

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  • Stephen Hawking and ALS
    good But I didn t die In fact although there was a cloud hanging over my future I found to my surprise that I was enjoying life in the present more than before I began to make progress with my research and I got engaged to a girl called Jane Wilde whom I had met just about the time my condition was diagnosed That engagement changed my life It gave me something to live for But it also meant that I had to get a job if we were to get married I therefore applied for a research fellowship at Gonville and Caius pronounced Keys college Cambridge To my great surprise I got a fellowship and we got married a few months later The fellowship at Caius took care of my immediate employment problem I was lucky to have chosen to work in theoretical physics because that was one of the few areas in which my condition would not be a serious handicap And I was fortunate that my scientific reputation increased at the same time that my disability got worse This meant that people were prepared to offer me a sequence of positions in which I only had to do research without having to lecture We were also fortunate in housing When we were married Jane was still an undergraduate at Westfield College in London so she had to go up to London during the week This meant that we had to find somewhere I could manage on my own and which was central because I could not walk far I asked the College if they could help but was told by the then Bursar it is College policy not to help Fellows with housing We therefore put our name down to rent one of a group of new flats that were being built in the market place Years later I discovered that those flats were actually owned by the College but they didn t tell me that However when we returned to Cambridge from a visit to America after the marriage we found that the flats were not ready As a great concession the Bursar said we could have a room in a hostel for graduate students He said We normally charge 12 shillings and 6 pence a night for this room However as there will be two of you in the room we will charge 25 shillings We stayed there only three nights Then we found a small house about 100 yards from my university department It belonged to another College who had let it to one of its fellows However he had moved out to a house he had bought in the suburbs He sub let the house to us for the remaining three months of his lease During those three months we found that another house in the same road was standing empty A neighbour summoned the owner from Dorset and told her that it was a scandal that her house should be empty when

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  • Relatives ask for  mercy killings
    support euthanasia but was keen to see the appointment of a palliative care clinician this will be recommended to the States later this month Deputies are due to discuss a report which recommends keeping voluntary euthanasia illegal in Guernsey although Health minister Peter Roffey has produced a minority report supporting the practice in limited specific circumstances The report recommends hiring a palliative care clinician to improve the quality of life for terminally ill patients which Mrs Martin said could be the crucial link in the chain We believe that in the majority of cases good palliative care should negate the need for euthanasia said Mrs Martin Even in those patients who have symptoms that are difficult to control it is possible to make these manageable so that they can cope She said that euthanasia was an emotive issue and when someone was either ill or close to someone who was it was difficult to be objective about the best course of action Each patient is an individual and have their own coping mechanisms and these may change at each new direction the disease process takes them she said It was important she added for patients to know that the hospice never stopped trying to find a solution because once people were told that nothing more could be done for them they were likely to feel abandoned Les Bourgs Hospice is just one organisation with which those diagnosed with a progressive disease will come into contact there is also their own doctor the Health Department and the Medical Specialist Group Mrs Martin believes that the recruitment of a palliative care clinician would bring all those aspects together Hopefully it would bring about a more coordinated consistent and complete service she said In addition to helping patients and their families a clinician

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