BUGNON . ODESC Réa LYONDécembre 2006

“good death” or the facilitation of a good death

• to cause death • intentionally • desire to promote the best interest • using the most gentle means

ευθανασ'ια

an “end of life without pain,comforted, peaceful, experiencing dignity and respect as well as closeness to family”

La dérive … • Darwin “The Origin of Species” 1859• Herbert Spencer “Social Darwinism”• The eugenics movement

– (forced) sterilization, quarantine, abortion, and even “euthanasia” of those thought to carry undesirable genetic material

• Alfred Ploetz “racial hygiene” 1895– the “Aryan” race

• lawyer Karl Binding / psychiatrist Alfred Hoche

The National Socialist Physicians’ League 19296% of the entire German medical profession

La dérive …

“Law for the Prevention of Hereditarily DiseasedProgeny” 1933 “The Nuremberg Laws” 1935

La dérive …

By 1942, nearly one-half of all physicians in Germanywere Nazi party members

La dérive …

the T4 Program (“Tiergartenstrasse 4” in Berlin) a “mercy death” to patients judged “incurably sick by medical examination”Hitler 1939 6000 children 200000 adults

La dérive …

The “euthanasia” program

sur le banc des accusés … ?

the “Physicians’ Trial” in Nuremberg (1946–1947)20 Nazi physicians and biomedical scientists accused7 acquitted

In Belgium

• Law on euthanasia : effect on 23 sept 2002

• « action on the part of a third person intented to end the life of someone who has requested it »

Patient

• Older than 18, legally competent, conscious at the time of the request

• Serious and incurable condition with constant suffering and unbearable physical or psychological pain which cannot be alleviated with medical or other treatment

Euthanasia is no longer a criminal offense provided that …

Request

• Volontary, carefully considered, repeated, without external pressure

• Written, dated, signed (possible help by someone without material benefit in the patiet’s death)

• Revocable at any time

Unbearable suffering ??

general wearinessno acceptable alternative

treatment

family or society coercion

Physician

• Fully informs patient about his health status, life expectancy, possible therapeutic options including palliatiative care

• Agrees with the patient that there is no other reasonable option

• Checks for real unbearable suffering, and repeats discussions to ensure that the request is not transient

• Consults another physician• Discusses the request with care-team and family if

wanted by patient• Is not obliged to perform a asked euthanasia provided

the medical chart is handed to another physician chosen by the patient

Advance directives

• Any individual may write a declaration in anticipation of a state in which euthanasia may be an option, but in which he would no longer be able or competent to make a decision

• May designate impartial trusted individuals to inform the phycisian about the presence of an advance directive

• May be made at any time provided it carries the signatures of two witnesses

• 5 years validity

Control process

• 1st document : details of the patient, physician, consultations related to the request

• 2nd document : more details on the reasons for and the nature of the request, and the method of euthanasia used

• National Comission of Control and Evaluation

(8 physicians (50% Pr) , 4 Pr of law, 4 involved in care of the terminally ill)

• Doubts : 1st document opened and case referred to the coroner

2 years later …

• 500 cases euthanasia• 0,2 % total death• 83% flemish – 17% french• The most prominent reasons for the request :

“pointless suffering” “deterioration or loss of dignity” “weakness or tiredness”

• 1 advance directive and unconscious• 64% > 60 years• 83% cancer – 13% neuromuscular• 48% specialist – 32.5% general practitioner –

19.5% specialist in palliative care• 54% in hospital – 41% at home• 81.5% barbiturates – 10% midazolam

In ICU …

• Patient often comatose, confused, too weak to organize his toughts

no request from patient : - is withdrawning or withelding of care in patients with no hope of a meaningful survival illegal ?

– Must we continue care ad infinitum even when acknowledged as futile by all involved ?

In ICU …

• Advance directive and surrogate nominated …– Is surrogate able to understand the complexities

of the situation, the options available and to take the good decision at a time of heightened emotional stress and anxiety ?

mechanical ventilation in pneumonia ??

Euthanasia = to achieve a good death Dignified, Peaceful, Pain-free, in presence of family and

friends

• may be helped by withdrawning and withholding care if adherence to bioethical principles

• Are intensivists illegal and do they need formal, signed approval if– effective communication and open discussion of all

options available– increasing doses of sedatives and analgesic agents

at the right time

are performed ???

Should legislation recognize that ?

Merci pour votre attention

Références …

End-of-life practice in Belgium and the new euthanasia lawIntensice Care Med (2006) Jean-Louis Vincent

Euthanasia and physician-assisted suicide in The

Netherlands