1. First Do No Harm Euthanasia in Belgium
Raphael Cohen-Almagor
April 15, 2017

2. Definitions
Euthanasia -- a practice undertaken by a physician, which intentionally ends the life of a person at her explicit request.
Physician-assisted suicide is different than euthanasia in that the last act is performed by the patient, not by the physician. The physician provides the lethal drugs to the patient who takes them by herself.
April 15, 2017

3. Concerns
(1) the changing role of physicians and imposition on nurses to perform euthanasia;
(2) the physicians’ confusion and lack of understanding of the Act on Euthanasia;
(3) inadequate consultation with an independent expert;
(4) lack of notification of euthanasia cases;
(5) organ transplantations of euthanized patients.
April 15, 2017

4. Euthanasia - Law Belgium accepted the Dutch definition:
(a) “euthanasia is the intentional taking of someone’s life by another, on her request”.
(b) It follows that this definition does not apply in the case of incompetent people; there the proposed terminology is “termination of life of incompetent people”.
(c) More importantly, the act of stopping a pointless (futile) treatment is not euthanasia and it is recommended to give up the expression “passive euthanasia” in these cases.
(d) What was sometimes called “indirect euthanasia”, forcing up the use of analgesics with a possible effect of shortening life, is also clearly distinguished from euthanasia proper.
April 15, 2017

5. Euthanasia - Law
The patient’s physician needs to inform the patient of the state of his/her health and of his/her life expectancy;
Discuss with the patient his/her request for euthanasia and the therapeutic measures which can still be considered as well as the availability and consequences of palliative care
April 15, 2017

6. Consultation
In both Belgium and Holland, the physician practicing euthanasia is required to consult an independent colleague in regard to (a) the hopeless condition of the patient, and (b) the voluntariness of the request.
Unclear to what an extent the independency requirement has been compromised.
April 15, 2017

7. Role of Physicians and Nurses
In both Belgium and Holland, the physician is required to devote energies in the patient and her loved ones, to consult with other specialists, to spend time and better the communication between all people concerned.
April 15, 2017

8. Palliative Care Role of the psychologist.
Palliative psychiatry can be helpful in managing symptoms alongside medical and nursing staff, such as pain, breathlessness, fatigue and treatment side-effects; clarifying issues of personal autonomy; coping with changes as a result of the patient’s condition, and managing feelings of uncertainty
April 15, 2017

9. Who Administers the Lethal Drug?
The law clearly stipulates that only physicians may administer the lethal drugs for euthanasia.
12% of nurses in Flanders administered the drugs, mostly without the physician co-administering
April 15, 2017

10. Physicians’ Confusion and Lack of Understanding of the Law
Two out of 10 physicians failed to label a hypothetical case in which a physician ended the life of a patient at the patient’s explicit request as “euthanasia.”
Three out of 10 did not know that the case had to be reported.
April 15, 2017

11. Consultation
In 35% of the cases (n=235) physicians failed to consult an independent specialist.
Disagreement between the first and the second physician in 23% of cases.
April 15, 2017

12. Consultation Since 2003, LEIFartsen in Belgium.
In Belgium, there are no rules regarding who decides the identity of the consultant.
The only rule is that the consultant needs to be independent.
Probably doctors approach like-minded physicians.
April 15, 2017

13. Reporting
In Belgium, all cases have to be fully documented in a special format and presented to a permanent monitoring committee, the National Evaluation and Control Commission for Euthanasia, established by the government in September 2002.
The Commission needs to study the registered and duly completed euthanasia document received from the physician.
Members ascertain whether euthanasia was performed in conformity with the conditions and procedures listed in law.
April 15, 2017

14. Reporting
According to the last report (2010) approximately half (549/1040 (52.8%) of all estimated cases of euthanasia were reported to the Federal Control and Evaluation Committee.
Timme Smets, Johan Bilsen, Joachim Cohen et al., “Reporting of Euthanasia in Medical Practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases”, BMJ, Vol. 341 (October 5, 2010).
April 15, 2017

15. Organ Transplantations
Organs of Belgian nationals or people who have lived in Belgium for more than 6 months can be removed after death, except if they have specifically stated refusal while they were still alive, or the deceased immediate family objects to it.
April 15, 2017

16. Organ Transplantations
Euthanasia can be planned.
Euthanasia donors accounted for 23.5% of all lung donors and 2.8% of heart transplant donors after cardiac death.
Euthanasia donors accounted for almost a quarter of all lung donors while euthanasia cases accounted for 0.49% of deaths.
April 15, 2017

17. Suggestions for Improvement
Would there be need for euthanasia if care were better organized?
Culture of Death?
Beneficence v. non-maleficence.
Do No Harm!
April 15, 2017

18. Palliative Care
In Flanders, about 10,000 patients receive daily palliative care.
Insufficient financial support from the Belgian government for local and national palliative care initiatives and research;
Lack of palliative care guidelines and standards for palliative care education;
Palliative day-care services is new;
In Flanders, no specialist accreditation for palliative care professionals.
April 15, 2017

19. Palliative Care
Palliative care knowledge and expertise of the average physician is very limited.
Most physicians have had no or very little training in palliative care.
The average general practitioner treats a few dying patients each year and has little experience in treating complex refractory symptoms.
April 15, 2017

20. Palliative Care
While the existence of adequate palliative care does not guarantee that patients would opt for life, there is evidence that:
referral to palliative care programs and hospice results in beneficial effects on patients' symptoms,
reduced hospital costs,
a greater likelihood of death at home,
a higher level of patient and family satisfaction than does conventional care.
April 15, 2017

21. Palliative Care
Patients with an enhanced sense of psycho-spiritual well-being are able to cope more effectively with their condition.
Emotional distress, anxiety, helplessness, hopelessness and fear of death all detract from psycho-spiritual well-being.
April 15, 2017

22. Palliative Care
Comprehensive palliative care, which includes anxiety relief, pain and symptom management, support for the patient and her loved ones, and the opportunity to achieve meaningful closure to life, should be the standard of care at the end of life.
April 15, 2017

23. Expert Consultation independence should be studied and reviewed’
Who is the consultant?
April 15, 2017

24. Expert Consultation LEIF exists only in small scale in Wallonia.
78.2% of physicians were aware of the existence of LEIF but only 35% of physicians who had received a euthanasia request since LEIF became active had made use of LEIF.
April 15, 2017

25. The patient’s attending physician
The patient’s attending physician, who supposedly knows the patient’s case better than any other expert, must be consulted, and all reasonable alternative treatments must be explored.
April 15, 2017

26. The care-givers Team
The care-givers should include specialist physicians, nurses, social workers, mental health professionals, rehabilitation therapists and community-based agencies.
Quality care requires investing time and attention, opening and maintaining two-dual way communication of listening and advising.
April 15, 2017

27. Role of social workers
It must be ensured that the patient’s decision is not a result of familial and environmental pressures.
It is the task of the social workers to create an open, supportive space in which the patient can feel safe to hold a candid conversation about her condition and wishes.
April 15, 2017

28. Conclusion Paternalism
60% of physicians think that they should be able to decide to end the life of a patient who suffers unbearably and is incapable of making decisions.
April 15, 2017

29. Holistic care
Holistic care must be compassionate, addressing the physical, psychological, existential and spiritual aspects of the patient’s dying experience.
All cases of physician-assisted suicide (PAS) and euthanasia should be scrutinized, examined, monitored, and studied carefully.
April 15, 2017

30. Thank you
April 15, 2017