End of Life Decisions

1
End of Life Decisions

• Presentation
• Anne Beyers

2
Definitions

• Euthanasia (frequency in Flanders estimated
  between 1.1 and 0.3 of the deaths) differs
  from
• Life termination on request of a third party
  (e.g. family or other caregivers) with a
  competent or incompetent patient (3.2 1.5)
• Assisted suicide request of a patient to
  prescribe or provide medicine which he or she can
  take at a chosen moment in order to commit
  suicide (0.1 0.01)

3
Definitions

• Intensify symptom treatment in order to shorten
  life e.g. intensify sedative medication with a
  patient suffering from suffocation(18.5 22 )
• Palliative sedation planned and agreed on with a
  terminal patient and his family/friends, intended
  to keep the patient asleep until his death (no
  frequency results)
• DNR stop or not start life prolonging treatment
  (16.4 15)

4
Palliative care

• When the care provided to a patient whos life
  threatening illness can no longer be treated
  curatively.
• Focus on the patient and family
• A right for every patient
• Attention for different ways and approaches of
  farewell

5

• Euthanasia
• DNR-protocol

6
Eutanasia

• 22nd of June 2002 the Belgian government accepted
  the law on active euthanasia
• 22nd of September 2002, 3 months after
  publication, every patient has the right to ask
  for euthanasia, in case he or she is experiencing
  unbearable suffering, with no perspective on
  recovery

7

• Virga Jesse Hospital
• Implementation of the law on active euthanasia
• Decision making protocol for terminal patients

8
STEP I (formal control and information by
physician)

• Request for euthanasia
• 2 questions for the physician
• Does the question fit in to the legal framework
  for euthanasia?
• quick answer
• Does the patient really ask for euthanasia or is
  there an other question underlying his so
  called request for euthanasia?
• Process to answer

9
Law

• Definition (1) deliberately ending a patients
  life (2) by a physician (3) on request of the
  patient.
• Principles of great meticulousness
• Person be of age ( or underage and removed from
  guardianship), conscious and competent
• Request voluntary, without external pressure,
  well considered, enduring, repeated
• Condition (objective) incurable
• Condition (subjective) continuous and unbearable
  physical or psychological suffering as a result
  of an incurable disease or accident
• Patient and physician are convinced no other
  reasonable solution is possible.

10

• Inform the patient
• Treatment
• Prognosis
• Complications
• Possibilities of palliative care
• Possibilities of social, spiritual, moral support
• Euthanasia procedures / protocol
• ! Registration in the medical file on date of 1st
  request !
• Proceed to STEP II
• or
• Medical indication for refusal
• Registration in the medical file
• Inform the patient
• Second opinion relating to the medical grounds

11
STEP II (Consultation / deliberation by the
physician)

• Request for euthanasia
• Discuss with
• ____________________________________________
• Nursing team palliative team general
  practitioner family (1)
• (1) Only with agreement of the patient

12
STEP III (Palliative filter)

• Conversation with the patient by a member of the
  palliative support team (2)
• (2) Only with agreement of the patient

13
STEP IV (confirmation of the request for
euthanasia)

• Patient sustains his/her request
• Patient withdraws request

14
STEP V (Implementation of the decision)

• Physician (treating the patient) agrees to
  perform euthanasia
• Explanation on the procedure
• discussion with the physician
• registration in medical file
• Consultation of 2nd physician
• (file access, examination and conversation with
  the patient.)
• Advise registered in medical file

• Physician is not prepared to perform euthanasia.
  He motivates his decisssion to the patient.
• Transfer of medical file to a physician appointed
  by the patient
• Patient receives (on request) support in
  contacting an other physician who can get advise
  from LEIF arsten (life-end information forum)

15

• Physician informs the patient on the results of
  the consult
• Discussion with family / relatives (on request of
  the patient)
• written request of the patient hand written and
  signed by the patient (in medical file), unless
  physical condition does not allow so. In that
  case the request has to be written by a mediator
  in the presence of the physician
• Performance of euthanasia (Physician can be
  supported by a member of the palliative support
  team).

16
STEP VI (Aftercare)

• Emotional aftercare
• Registration form for the Federal Control- and
  evaluation commission
• A copy of the anonymous part of the registration
  form or report to the physician in charge.