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Abstract
Background In 2002, Belgium set a legal framework for euthanasia, whereby granting and performing euthanasia is entrusted entirely to physicians, and—as advised by Belgian Medical Deontology—in the context of a trusted patient–physician relationship. Euthanasia is, however, rarely practiced, so the average physician will not attain routine in this matter.
Aim To explore how general practitioners in Flanders (Belgium) deal with euthanasia. This was performed via qualitative analysis of semistructured interviews with 52 general practitioners (GPs).
Results Although GPs can understand a patient's request for euthanasia, their own willingness to perform it is limited, based on their assumption that legal euthanasia equates to an injection that ends life abruptly. Their willingness to perform euthanasia is affected by the demanding nature of a patient's request, by their views on what circumstances render euthanasia legitimate and by their own ability to inject a lethal dose. Several GPs prefer increasing opioid dosages and palliative sedation to a lethal injection, which they consider to fall outside the scope of euthanasia legislation.
Conclusions Four attitudes can be identified: (1) willing to perform euthanasia; (2) only willing to perform as a last resort; (3) feeling incapable of performing; (4) refusing on principle. The situation where GPs have to consider the request and—if they grant it—to perform the act may result in arbitrary access to euthanasia for the patient. The possibility of installing transparent referral and support strategies for the GPs should be further examined. Further discussion is needed in the medical profession about the exact content of the euthanasia law.
- General practice
- end-of-life practices
- euthanasia decision-making
- euthanasia
- care of the dying patient
- primary care
- drugs and drug industry
- elderly and terminally ill
- primary care
- public health ethics
- education for health care professionals
- euthanasia
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- General practice
- end-of-life practices
- euthanasia decision-making
- euthanasia
- care of the dying patient
- primary care
- drugs and drug industry
- elderly and terminally ill
- primary care
- public health ethics
- education for health care professionals
- euthanasia
Introduction
Research in several countries has shown that physicians do not limit end of life (EoL) care strictly to rendering palliative care until the patient dies a natural death. In a considerable number of cases, they intervene more actively and influence, intentionally or unintentionally, the time of death.1 The central motive for this intervention is to relieve hopeless suffering.2 Physicians however perceive EoL decisions, and especially requests from patients for their assistance in dying, as one of the most difficult ethical decisions they face,3 all the more so because actions to intentionally hasten death are illegal in most countries. Patients with incurable conditions who are seriously ill can certainly harbour—often in spite of a remaining desire to live—a wish to die. In these cases they prefer euthanasia to physician-assisted suicide as a more dignified and failsafe alternative.4
In 2002 euthanasia in Belgium was given a legal framework. Belgian law defines euthanasia as ‘the intentional termination of a patient's life by a physician at the patient's request’. The law considers patient's needs and the physician's possible reservations. The patient is allowed to judge his/her burden as persistent and unbearable and to request euthanasia, but he/she cannot demand it. The attending physician must ensure that the patient meets all statutory requirements (table 1). He/she must agree with the patient that the suffering cannot be alleviated and that there are no reasonable treatment alternatives. He must comply with the legal procedures (table 1). A physician, however, is not obliged to perform euthanasia. He may attach extra conditions (besides the legislated requirements) to his agreement, such as additional advice from a palliative team or may refuse on medical (criteria not satisfied) and/or conscientious grounds. He is not legally bound to refer the patient, although this is strongly recommended from a deontological view.
Overview of Belgian law on euthanasia
Belgian legislation does not indicate which physician should perform the act. It merely stipulates that the performing physician has to comply with the legal requirements. After the enactment of the law, the Belgian National Council of the Order of Physicians and medical professional organisations advised that euthanasia should take place within a trusted patient–physician relationship and pleaded against the establishment of euthanasia teams.5 The implication of this stance is that a physician who accepts a request for euthanasia is expected to carry it out.
Country-specific research shows that legalisation raises the general acceptability of euthanasia among physicians and their overall willingness to perform it.6 7 Euthanasia is, however, rarely practiced, even when legalised.8 9 As a result, the average physician, including general practitioners (GPs), will not attain routine in this matter.
The aim of this qualitative study is to explore how GPs in Flanders (Belgium) deal with euthanasia in the light of its legal status, the high degree of commitment expected from GPs and GPs' lack of routine in this matter.
Methods
The study presented in this article is part of a large qualitative survey of patients who were terminally ill who were cared for at home, in which 50 patients were followed from the moment they were labelled ‘terminally ill’ until death. Recruitment of patients was based upon GPs' registration of a patient as ‘terminally ill’ with his/her (state-supervised) Health Insurance Fund so that an allowance for palliative care could be issued. Here we report the results of interviews with GPs after the patients' death. The entire project started in February 2007 and was completed in October 2008.
The interviews with the GPs were semistructured and focused on the following topics: personal–ethical and legal issues surrounding EoL practices; personal resilience and decision making in the care of the patient who is terminally ill; estimated medical knowledge about EoL practices; communication styles with the patient and the next of kin; experience with and willingness to perform euthanasia. The interviewer was able to record the GPs' spontaneous interpretation of the euthanasia law since no introductory definition of the term euthanasia had been given. In some cases, not all topics were discussed or the interview ended prematurely for practice-related reasons (start of consultation). All the interviews were audio taped, transcribed verbatim and analysed. A coding frame was constructed by two independent coders. Statements were categorised into expected and newly added topics, using the qualitative data-indexing package NVIVO 8 (QSR international, Doncaster, Australia).
Results
Characteristics of GPs
Of the 53 GPs, 1 refused the interview. Of the 52 participating, 37 were men. The mean age was 51 years, ranging from 29 to 82 years. On average, the GPs had been practicing for 26 years, ranging from 4 to 57 years. In all, 22 identified themselves as adherents of an organised religion (Roman Catholic); 14 saw themselves as religious only to the extent that they abided by the human values normally contained in religions; 16 claimed to be not religious in any way.
Interviewees' interpretation of euthanasia definition
Almost all the GPs consider lawful euthanasia to be only those acts where a lethal injection is given that immediately ends the patient's life on his request. According to the GPs, this is a definition shared by the patients themselves in that, when expressing the wish to end their life, they mostly allude to ‘receiving a fatal injection’ rather to ‘a painless way of dying’. As a consequence, many GPs perceive EoL practices such as increasing opioid dosages and palliative sedation, when provided to gradually speed up death, as falling outside the scope of lawful euthanasia.
Only one of the GPs used a broad definition of euthanasia, whereby the term encompasses any means of deliberately ending life on a patient's request, be it quick or gradual.
The next two sections take a closer look at the GPs' narrow interpretation of euthanasia. The section immediately following these focuses on the GPs' views on medical practices with potential life-shortening effects.
Interviewees' experiences with euthanasia (September 2002–October 2008)
A total of 28 of 52 GPs had never received an explicit euthanasia request. Four of these admitted that they discouraged requests by saying in advance that performing euthanasia was not an option for them.
In all, 15 of 52 GPs had been confronted with at least 1 euthanasia request but had never performed it. GP-related reasons for this non-performance (in 10 of these cases) were: the GP postponed his/her decision (2); the GP refused the request without referral (1); the performance failed: euthanatics were unavailable at the pharmacy (2); the GP granted the request and asked another doctor to administer the lethal injection (5). Patient-related reasons for non-performance in the remaining five cases were: the patient died before the euthanasia could be carried out (one patient); the patient decided finally not to use euthanasia (two patients); the injection was converted to palliative sedation on the family's demand, with the patient's consent (two patients).
In all, 9 out of 52 GPs had performed euthanasia (once: 5 GPs; twice or more: 4 GPs).
GPs' views on euthanasia
Euthanasia is accepted as a tolerable practice but individual readiness to perform it is limited
All the GPs acknowledge that life situations may occur in which a request for euthanasia is quite understandable. GPs feel committed to relieving a patient's suffering and most agree that euthanasia is acceptable as one of the EoL options. However, reservations about euthanasia are expressed, and are based on two factors. First, giving a lethal injection is felt to be a very harsh and harrowing way to end life for most GPs. Second, a physician who accepts a request is expected to carry it out.
(GP51, male, 38 years old, no procedures) …Killing someone yourself, that's one step too far. But if it's also part of helping a patient, and the patient asks for it, then, yes. Oh well, I still am kind of confused, you know? I: Is it the lack of experience that bothers you most? GP: Oh no, absolutely not. I'm perfectly able to do it. I will find the right blood vessel, and I know which products I should use. But, to really carry it out, I don't know. That man or woman still remains a patient of yours, you see.
(GP23, female, 53 years old, no procedures) …Now we have to inject, huh, do you want to or not? GP: Of course, [as a doctor] you can decide yourself, but sometimes it's also difficult because you have built a bond with your patient and then actually say: ‘ah, this last thing, that's not for me’.
The GPs' decision-making process is affected by the demanding nature of the request, by the GPs' personal view on which grounds euthanasia is legitimate and by the GP' individual ability to administer ‘the lethal injection’.
The relationship with the patient
The request in itself, especially from a long-standing patient, can overwhelm some GPs. Some GPs will grant the request because of the existing relationship. Others feel obliged to perform, although ethically and emotionally they do not feel ready. For others, it is exactly this long-standing relationship that makes them unable to comply.
(GP48, male, 53 years old, one procedure) You don't enjoy it, huh. But I think, if you have assisted the people for so many years, then you mustn't pull out at the end.
(GP27, male, 65 years old, no procedures) I don't know whether I can do this with my own patients. Perhaps I could if the question came from a stranger.
Circumstances that render euthanasia legitimate
For most of the GPs, the main dilemma is determining what kind of suffering is eligible for euthanasia and who should determine it. (The dichotomy between the inviolability of human life and the patient's right to die is perceived as less of a dilemma.)
A minority of interviewees refuse euthanasia on religious grounds. They are convinced that dying naturally is worth striving for and therefore they promote palliative care. One of these GPs would refuse without referring. Two would steer the patient away from this unacceptable way of dying by deliberately postponing a decision and thus try to gain time until the patient dies a natural death. A further three would not impose their conviction and would refer.
(GP55, female, 38 years old, no procedures) …My resistance to euthanasia is religious. It's like ‘thou shalt not kill’. We have discussed this many times in the group practice. I will pass on a request to a colleague who does not object to carrying out euthanasia but I will NOT attend! Because then I would do it myself.
Most interviewees recognise a suffering patient's right to die. Opinions, however, diverge strongly on how to define the nature and level of suffering that render euthanasia legitimate and on the extent of the patients' autonomy.
One group of GPs refer to a ‘medical impasse’, a noticeably intolerable and hopeless medical condition, as a necessary requirement. They will not grant a request in cases of anticipation of an expected burden or lack of will to live. They often add limiting conditions beyond the legislative criteria, such as terminal state or failure of preceding palliative care.
(GP34, male, 59 years old, no procedures) I need to personally feel that I am completely powerless, I have done my utmost but the patient keeps on suffering terribly. Anyone can see that this situation has become insufferable and that there's no alternative.
Others give priority to the patient's autonomous judgement of unbearable suffering. For them, the well considered and enduring request of the patient in itself is sufficient. In this perspective, suffering takes on a wider meaning, to include serious mental and existential suffering such as loss of dignity. These GPs seldom add extra limiting conditions.
(GP9, male, 53 years old, one procedure) My personal view is that, if a patient is fully conscious and he says: ‘I've been thinking enough about it now’, and if you have already had a number of serious conversations on the subject, and he finally decides that he can't go on like this anymore, well, then, yes.
Individual ability to administer ‘the lethal injection’
Many of the GPs dread administering a lethal injection. They fear they lack the necessary technical skills or shy away from this ‘unnatural gesture’ or feel a moral shudder (‘who am I to take someone's life’), even if it feels right to them in a moral sense. Among the GPs who do not object to euthanasia on principle, we can distinguish three groups. A first group is not reluctant to inject. A second group can imagine performing euthanasia but dreads carrying out the act. Members of this group are typically those who interpret suffering in the strictest sense and who add limiting conditions for performing the act. Half of them would appreciate the assistance of an experienced physician during the performance. Lastly, there is a group that feels incapable of injecting due to technical, intuitive or moral inhibitions. Members of this group would overcome these inhibitions by referring the patient or even by guiding the patient through the euthanasia process, but would require another physician present to carry it out.
(GP21, female, 57 years old, no procedures) Speaking for myself, I have no problem with it at all. The only thing I would have a problem with is that I've never done it, more the practical side of things. That I would mess up at a time where you can't mess up. But for the rest…no.
(GP7, male, 62 years old, no procedures) …Not only out of religious reasons. Don't ask me to shoot a cat, I really wouldn't be able to do it. Yet I go hunting. (Laughing).
(GP24, male, 56 years old, no procedures) A lot of GPs would find it easier to talk about euthanasia if there were that nuance, that you could say: ‘I want to help you and I will be there for you until the end, your personal GP’—but I will not give the injection myself, someone else has to do it.
Need for a sense of security
Several of the GPs stressed the importance of being supported by colleagues while a request is being processed and especially when performing the act.
(GP13, female, 30 years old, no procedures) It is an advantage that there are two of us, that we can support each other. Supposing we have to euthanize, that we can go together. Most patients who come here know both of us
Feelings concerning the legalisation of euthanasia
About a quarter of the interviewees feel comfortable with the present legislative framework for euthanasia. To them euthanasia has a full right to legal recognition. They feel protected by the law and also able to abide by it.
(GP12, male, 54 years old, no procedures) The legislation as it is now isn't that bad. Wonderful that it's possible, wonderful that we have legislation.
Several GPs stand by the legislation but do not feel ready ‘to handle it’.
(GP8, male, 38 years old, no procedures) If it's euthanasia, I don't think it's very clear, all that paperwork etc. I try to get out of it […] or I have the patient admitted. I: In itself, are you against it? D: I am not against it, absolutely not […] It's because I don't know how to handle it; I haven't been trained for this…
(GP17, male, 59 years old, no procedures) I'm ready for it! Should anyone ever ask for euthanasia, I will assess it, and I know the legal framework, … huh, probably I won't do it myself, because I don't have any materials or means for it.
There is also, however, resentment. Some GPs experience the legislation as a social imposition that threatens to overshadow their own convictions. A few feel that the legislation is too controlling, that it has taken euthanasia practice out of the ‘colloque singulier’ with the patient.
(GP6, male, 47 years old, no procedures) I will do what's necessary. I will say that I have an ethical problem, but that I want to respect that man; that I'm not above the law, […]. If you did it 20 years ago, you got thrown in jail; if you don't do it now, you end up in jail too. How society can change, huh?
(GP2, male, 63 years old, one procedure) The legislation came to prevent abuse, but I found it easier when the legislation wasn't there.
GPs' view on gradual ways to hasten death as opposed to life-terminating acts: both euthanasia or not?
Many interviewees brought up the issue of practices with potential life-shortening effects such as opioid use and palliative sedation (ie, administering sedatives to render the patient unconscious until death occurs). When applied in doses to address pain and symptoms, these practices basically do not hasten death. Opinions, however, differed among the interviewees as to whether these practices may also be provided to (co)intentionally hasten death on the patient's request and whether they are then classed as euthanasia or as an appropriate form of terminal care.
Some of the GPs clearly separate the use of opioids and palliative sedation only to address symptoms on the one hand from euthanasia (ie, a life-ending injection) on the other hand. Several of them, however, added that titrating a symptom-relieving dose is not always feasible and that the line between involuntary and intentional overdosing is very thin.
(GP24, male, 60 years old, one procedure) She was very short of breath and well, we couldn't do anything about it anymore. And with her it had been agreed upon palliative sedation. And at a certain moment she also said ‘I don't want to wake up anymore’. And so we have used a subcutaneous pump and sedated her […], but then she woke up! Panic! The whole family was panicking. And then I gave her some intravenously, and after an hour she quietly slipped away. That is one way to euthanize, but yes, at that moment it was only meant to be palliative sedation. It was an emergency solution.
Other GPs do not make this distinction. Moreover, they prefer life-shortening measures to a lethal injection as a more humane way to assist a patient's death on his request, which they then consider as falling outside the scope of euthanasia legislation. They do, however, recognise that they are working in a grey zone between symptom alleviation and the ending of life.
(GP17, male, 59 years old, no procedures) … [when deliberately increasing opioid dosages instead of administering a lethal injection] …you are very close to euthanasia. But there is a fundamental difference. You inject someone to death and here you're helping someone […] out of compassion, that it's been enough now, right, for this person.
For one GP it is clear that euthanasia embodies the concept of deliberately ending life on a patient's request, by any means, be it quick or gradual.
(GP36, male, 53 years old, six procedures) (…about acts to hasten death proposed as an alternative to euthanasia) I think this is just fooling yourself and society; it's not honest. That those physicians tell the patient: ‘we will take a natural course’ and that they don't do this at all, but that they use these means in such a way that they conceal from others and most likely also from themselves that they are actually euthanizing.
Reasons for preferring life-shortening measures and not considering them as euthanasia:
Setting a fixed time to say farewell and then stopping life is perceived as unnatural and shocking for GPs and the next of kin. Imitating a natural dying process is more acceptable.
(GP11, male, 55 years old, two procedures) Palliative sedation is a much more human way. Yes, I try to convince patients to go for this! I feel: euthanize: if there really is no other way. I feel the patient has the right to die if nature doesn't follow. But a palliative sedation, for me as a doctor, is much more acceptable. And towards the relatives for instance; they do not fully comprehend what [injecting someone to death] is. To see someone lying there, ah.
If a patient makes his wish to die known, GPs might question whether it is really a request to end life or just one to end suffering, especially if the patient still shows a certain will to live. We found that the more GPs are reluctant to give a life-ending injection, the more they are convinced that the patient is not really asking for immediate death but simply wants to slip out of life painlessly and peacefully. Gradual methods meet these demands more effectively and, since it is the shortening of suffering and not death that is their primary goal, they belong to regular medical practice.
(GP36, male, 53 years old, six procedures) For me, it's perfectly reconcilable that a patient still may have a certain will to live but at the same time is preparing himself for a peaceful death. I can understand why a patient, being afraid of losing his dignity in the course of his disease, at a certain point in his illness says ‘now’.
(GP11, male, 55 years old, two procedures) The patient asks for euthanasia, but is in fact not asking for euthanasia. He often asks for a dignified death; as little as possible or no pain. Soft. Acceptable. And a nice death. That is his question, as I see it.
Life-shortening measures without an explicit request
Finally, in discussing the need to intervene in serious suffering, various GPs brought up the issue of life-shortening measures without an explicit request. When doing so, they cited two situations: first, shortening the length of the patient's final phase of agony, when the death throes have started; second, facilitating the death of the terminally ill, demented and inhumanly deteriorated patient. Aware of the grey zone between symptom alleviation and the intentional shortening of life, they advance the need for a certain ‘colloque singulier’ with patient or next of kin and some medical flexibility in supporting the patient throughout the dying process. The aims are to shorten the length of misery, ensure a relatively comfortable death and alleviate the burden on the next of kin.(GP22, female, 57 years old, no procedures) …That struggle that you have on your hands: it is no longer human at that moment and on the other side, you are able to do it, you are not allowed to do it. They [the family] look at you and say: ‘you're the one who can do it and you can solve this for us here, huh, end that no longer human life’. But if there is no last will, then it's not possible, right? And sometimes I find this very hard for me!
(GP40, female, 39 years old, no procedures) …I wouldn't be afraid of doing anything which would cause them to die earlier. It's not as if you want those people to die as quickly as possible. At that moment, that's actually not important anymore. Keeping the patient free of complaints should be the main concern!
(GP2, male, 63 years old, one procedure) …So indeed, increasing the dose in such a way that, you know, finally it will be too much and the patient will pass away: ethically or religiously I have no problem with it, if it is really during the final days.
Discussion
So far, only a few qualitative studies, conducted in The Netherlands, have examined GPs' emotions and decision making regarding euthanasia.10 11 In this qualitative study we have added to this line of research by exploring the readiness of Flemish GPs to perform euthanasia in the context of a legal framework. It has become clear that these GPs quite understand a patient's request for euthanasia under certain circumstances, and that most accept the legitimacy of euthanasia. However, it is also obvious that the GPs equate euthanasia with terminating life by a lethal injection and that many of them find this act difficult to deal with.
Four attitudes to euthanasia can be identified, moulded by GPs' own life views and the extent of their squeamishness about personally carrying out the act.
Willing to perform euthanasia: these GPs value the patient's autonomous judgement of unbearable suffering. They also adhere to a relatively broad interpretation of suffering. They dare to inject a lethal drug and feel comfortable with the euthanasia law. They are the most open to requests for euthanasia.
Only willing to perform euthanasia as a last resort: for these GPs, the objective medical condition is decisive: it must be so hopeless and intolerable that they can endorse euthanasia as the only solution. They tend to add limiting conditions beyond the legal ones. They dread having to carry out the act and many want practical assistance.
Feeling incapable of performing: these GPs belong either to type 1 or 2, but their inhibitions about administering a lethal injection dominate their attitude to euthanasia. They are willing to guide the patient through the euthanasia process but require another physician to perform the act itself.
Refusing on principle: these GPs feel that dying in a natural way is worth striving for; palliative care is the only option for them.
One must not cut and deal too
Since Belgian medical deontology advises that euthanasia should take place within a trusted physician–patient relationship, it is the GP who actually has to assess the request and—if he grants it—has to perform the act. In The Netherlands, which has similar legislation and deontology on euthanasia, Rietjens et al have already pointed out the consequences of this double role. Their hypothetical case study showed that, when it comes to assessing a patient's suffering, GPs apply more stringent criteria than impartial physician–consultants and even members of the Dutch Euthanasia Evaluation Committees.12 Given the GPs' divergent attitudes to euthanasia that are shown in our study, this double role may result in a difficult and particularly arbitrary access to euthanasia for the patient, especially since neither a statutory referral duty nor transparent referral strategies have been established.
We would stress three issues that create randomness of access. First, the demanding nature of the request from a patient with whom the doctor has developed some sort of personal relationship can have opposite effects, sometimes facilitating acceptance, sometimes inhibiting it.
Second, the legal criterion relating to ‘unbearable suffering due to incurable disorder’ seems open to divergent interpretations. This has also been recorded in The Netherlands: Buiting et al have pointed out that the euthanasia law entrusts the physician with a double task, namely understanding the patient's personal, subjective judgement of what constitutes intolerable suffering, but also objectively assessing the patient's medical condition with respect to intolerable suffering.13 Our study shows that Flemish GPs handle the duality of this task by emphasising either the empathising role or the strict medical professional role. The euthanasia law indeed allows for this duality since it does not elaborate on the criteria of suffering beyond the vague statement that ‘the doctor must ensure that the patient is suffering unbearably of an incurable disorder and must be convinced, together with the patient, that the suffering is beyond human intervention’.
Third, reluctance to inject, even when the GP finds a request valid, could lead to avoidance. Many interviewees articulate a wish for the presence of an experienced physician when euthanasia takes place, to provide technical and mental support or to execute the act itself. This situation differs from The Netherlands: Dutch GPs also experience euthanasia as distressing10 11 but apparently they seldom require practical support.14 This is despite the fact that the average Dutch GP is not significantly more experienced with life-terminating interventions than his Flemish colleagues.8 9 An influencing factor may be that in one in seven of their euthanasia cases Dutch physicians use a drinkable mix of barbiturates,15 a method that requires little technical skill but is very seldom used in Flanders.16
A possible explanation for these differences in readiness to inject is that the historical circumstances of implementation have been very different. In The Netherlands the legislation was carefully prepared and implemented in 2001, with the strong involvement of and explicit guidelines from the Royal Dutch Medical Association, whereas in Belgium the Euthanasia law was debated and passed rather swiftly in 2002, with little involvement of the medical profession.17 Belgian medical euthanasia guidelines were as good as non-existent until 2008.
It is surprising that the reluctance many GPs experience when having to intravenously inject a seriously ill person to terminate life, in the presence of fearful and sad next of kin, goes unnoticed in many euthanasia studies. GPs' need for practical support is illustrated by a report from the Life End Information Forum in Flanders, a voluntary network of physician–consultants on euthanasia. Life End Information Forum physicians are—if necessary—willing to be present for the emotional and practical support of the GP when euthanasia takes place. They report that in one out of three such cases they are asked to administer the lethal dose themselves, although this is beyond their official remit.18
Gradual alternatives as opposed to life-ending injections: both euthanasia or not?
Belgian law defines euthanasia as ‘the intentional termination of a patient's life by a physician at the patient's request’. It does not, however, define any euthanasia techniques or timeframe. It is clear from the annual findings of the Belgian Euthanasia Evaluation Committee, in which almost all reported cases of euthanasia involve life-ending injections,16 that Belgian doctors tend to interpret ‘intentionally terminate life ’ as ‘intentionally achieve immediate death’. In 2006, the Belgian Federal Euthanasia Evaluation Committee made clear that the law encompasses any means of deliberately ending life on the patient's request, be it quick or gradual.16 Notwithstanding this clarification, most interviewees hold on to the narrow denotation, thus leaving blank a wide grey area between symptom alleviation and the ending of life. This narrow interpretation of lawful euthanasia has also been reported in The Netherlands.19
Certain elements indicate that this narrow denotation is almost to be expected. First, the Belgian legal definition in itself is insufficiently elaborated and therefore prone to different interpretations. Obviously, GPs think that a law on euthanasia was only needed to create clarity on life-ending measures which take place in a time frame that can vary from minutes to hours, thus ensuring societal control and legal protection for the parties involved but not for life-shortening measures where the time frame clearly stretches over days. Second, all medical euthanasia guidelines in all countries where euthanasia has been legalised encourage the notion that euthanasia is an abrupt act by indicating the use of barbiturates (orally or injected) and neuromuscular relaxants (injected) as the preferential method.
Third, many GPs tend to feel that life-shortening medical acts are in the same league as palliative care (ie, they alleviate intense suffering and pursue a human process of dying) because it is the shortening of suffering and not death which is their primary goal. Just as giving a lethal injection is a harsh and emotionally demanding way to end life, watching a slow dying process may be just as harsh and harrowing, especially if the patient is inhumanly deteriorating, exhausted and asks that the process be sped up. Since life-shortening techniques may help create the illusion of a serene and natural-like dying process, they take away the notion of it being lawful euthanasia even more.
The issue as to whether intentionally shortening the period of suffering before inevitable death should be considered euthanasia is still a point of discussion among medical ethicists and part of the medical profession worldwide.20
Life-shortening measures without an explicit request
Our study also identifies a gap between the prevailing ethical and legal regulations and physicians' moral and clinical views on life-shortening measures without an explicit request. It seems that the more the patient is inhumanly deteriorated and death is imminent, the more GPs sense that the decision to facilitate death, with or without the patient's involvement yet often with the involvement of the next of kin, is part of regular medical practice. Apparently, when dealing with the final moments of life, doctors no longer see a sharp line between life and death but rather a gradual and inevitable transition from the one state to the other that—if necessary—may be gently hastened. The goal is to shorten the length of the patient's futile misery and to alleviate the burden on the next of kin. In Flanders, the number of (illegal) life-shortening measures taken without an explicit request still equals the number of life-ending/shortening measures taken on explicit request.21 The practice of intentionally hastening death without explicit request also exists in countries without euthanasia legislation.22 23
Strengths and limitations of this study
First, the description above of the GPs' attitudes towards euthanasia is based on data collected by means of interviews. Possibly, the interviewees would act differently in real life situations. Nevertheless, interviews are a suitable instrument to study intentions and fears. Second, the GPs may have had difficulties in vividly recalling their euthanasia-related experiences over a period of 6 years. However, our main goal was not to obtain exact data; this is a retrospective study with an exploratory character.
Lastly, the study group is not a representative sample of Flemish GPs. The fact, however, that recruitment was based upon GPs' registration of a patient who was terminally ill and not upon their opinions on euthanasia assures that this group is probably a fair reflection of Flemish GPs as a whole. In addition, by interviewing GPs of different ages, life views, experiences with euthanasia and location, this study meets the requirements of a qualitative investigation.
Conclusions and implications for practice
This study presents a broad overview of the contextual factors that affect Flemish GPs' readiness to perform euthanasia. Many issues require further in-depth investigation involving a representative group of GPs.
The possibility of instituting transparent referral and support strategies for the GPs should be further examined. This would give all patients equal access.
In current EoL medical guidelines, a sharp normative line is drawn between euthanasia directions (administering fast acting euthanatics) on the one hand and palliative sedation directions (administering sedatives in doses as much as necessary to address symptoms only) on the other hand. Given GPs' misgivings regarding life-ending injections, an alternative softer way of performing euthanasia is required, for example, a specially adapted palliative sedation protocol with doses that reduce the length of life. This could encourage the notion among physicians that this EoL act is then part of lawful euthanasia and should also be registered.
Lastly, the demand of GPs for a certain ‘colloque singulier’ with the patient/next of kin and for some medical flexibility when supporting the patient throughout the dying process needs further research and ethical debate. This could contribute to defining certain ‘good practice’ criteria for intense symptom alleviation close to death.
Acknowledgments
We thank all 52 GPs for their contribution to this study and for sharing so open-heartedly their experiences, opinions and fears with us. All the interviews were conducted in the Flemish variety of the Dutch language. We thank Mayke Hundhausen and Ann Cardinael for providing assistance in the verbatim transcription and coding of the interviews and Greet Vandenbussche for translating the directly quoted material into English. The original Dutch language responses are available on request from the authors.
References
Footnotes
Competing interests None.
Ethics approval The study received approval from the ethics committee of the University Hospital of Ghent University EC Project No.: 2007/084. Belgian Registration No.: B67020071901.
Provenance and peer review Not commissioned; externally peer reviewed.
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