public policy phd course research methodology on public policies: some “success stories”...

Public Policy PhD Course

Research Methodology on Public Policies:

some “success stories”

Euthanasia in Netherlands From Evidence Based Medicine to Evidence Based – Decision

Making (Legalization)?


INTRODUCTION

BackgroundNetherlands was one of the few countries where euthanasia and physician- assisted suicide was regulated by law, under strict conditions;

The enactment of the euthanasia law was preceded by several decades of debate among medical practitioners, lawyers, ethicists, politicians, and the general public.

2002 euthanasia act came into effect in the Netherlands, under strict conditions


INTRODUCTION

BackgroundRobust empirical research should be done to assess the end-of-life care consequences of legalizing euthanasia in this country.

At the end-of-life many patients needs comfort oriented – care…(What is comfort oriented – care?);

Such care might include end of life decision making;

Suffer becomes overwhelming;

Patient Explicit Request;

What is considered older people / incompetent patients;

1973

1984

1985

1990

2002

Before 1973, euthanasia was illegal in the Netherlands.

In that year, a doctor was arrested and put on trial for killing her terminally ill mother with morphine. The court gave her a suspended sentence of one week in jail and a year's probation. This set a precedent, and the courts quickly established a set of guidelines for when it was permissible for physicians to assist a patient in committing suicide, such as requiring certain consultations, insisting that the patient must be suffering from a terminal illness, and that

the patient must request it. the Royal Society of Medicine issued "rules of careful conduct" for euthanasia. These called for the doctor to inform the patient of his condition, consult his nearest relatives (unless he objects), consult at least one other physician, keep written records, and, in the case of a child, obtain the consent of the parents or legal guardians.

In 1985 a court dropped the "terminal illness" requirement in a case involving a young girl with multiple sclerosis. While her disease was incurable, there was no reason why she could not have lived indefinitely. (In a more recent case a woman who was perfectly healthy but suffering from severe depression was euthanized at her request.) By the late 80's it had become routine to "euthanize" babies born with handicaps, like Down's syndrome and spina bifida.

Three nurses in Amsterdam killed several comatose patients without any consent. They were convicted, not of homicide, but of failing to consult a physician.

In 1990, physicians in the Netherlands were involved in 11,610deaths, or 9% of all deaths in the country. of these, half were labeled "active involuntary euthanasia", that is, the patient was killed without his consent.

The Dutch Parliament legalize euthanasia and assisted suicide.

Euthanasia in Netherlands: a Brief History

c


http://www.pregnantpause.org/numbers/netheuth.htm

Patients Euthanized, Netherlands, 1990

Sources:Medische Beslissingen Roknd Het Levenseinde: Rapport van de Commissie Onderzoek Medische Praktijk inzake Euthanasie (Medical Decisions About the End of Life: Report of the Committee to Investigate the Medical Practice Concerning Euthanasia) The Hague, 1991

Wich

3100

8110

400

M orphineOverdosesIntended toTerminate

Life

P hysician-AssistedSuicide

ActiveEuthanasia

3159

2100

4951

1000

400

M orphine Overdoses Intended toTerminate Life

P hysician-Assisted Suicide

Active Euthanasia

With P atient's Consent Without P atient's Consent


1171 Journal of Medical Ethics

1508 PubMed

3822 Medicine, Health Care and

Philosophy

A simple search: Euthanasia and Netherlands



INTRODUCTION

J Med Ethics. 2006 April; 32(4): 240–245.


Clarifying some concepts.

Euthanasia – Administering a lethal drugs by a physician with the explicit intention to end a patients life on the patients explicit request.

Physician Assisted Suicide The patient self –administers medication that was prescribed intentionally by a physician to end a a patients life..

Voluntary Euthanasia – (Explicit Consent) the person concerned asks someone to help them die, perhaps by asking for help to take an overdose of painkillers

Involuntary Euthanasia – (No Explicit Consent) euthanasia is carried out without the patient’s consent, for example, if they are in a persistent vegetative state and no longer able to live without a life-support machine, which is then switched offhttp://www.bbc.co.uk/ethics/euthanasia/overview/forms.shtml

INTRODUCTION

Clarifying some concepts.

Euthanasia (active and passive)Voluntary, non-voluntary and involuntary euthanasia can all be further divided into passive or active variants.

Passive euthanasia entails the withholding of common treatments, such as antibiotics, necessary for the continuance of life.

Active euthanasia entails the use of lethal substances or forces, such as administering a lethal injection, to kill and is the most controversial means.

http://www.bbc.co.uk/ethics/euthanasia/overview/forms.shtml


INTRODUCTION


INTRODUCTION

A Longitudinal Study

Published online July 11, 2012

www.thelancet.com


METHODS

Study Design

A Longitudinal (retrospective) StudyRandom SampleCentral death registry os Statistics Netherlands (all deaths and causes reported)Period studied was Aug 1 – Nov 1 in all studied years;

Questionnaire (mailed 8496 – 6263 returned – rate 74%)

(1) Whether the respondent had withheld or withdraw medical treatment while taking into account the possible hastening of death;(2) Whether the respondent had intensified measures to allevite pain or other symptoms while taking into account or party intending the possible hastening of death;(3) Whether the respondent had withheld or withdrawn medical treatment with the explicit intention of hastening death;(4) Whether the respondent had admnistered, supplied, or prescribed drugs with the explicit intention of hastening death, resulting, in the patient death’s.


RESULTS

In: The Lancet 2012, July 11


RESULTS

141

257

310

21

4564

4224 13

294

475

1825 25 17

0

100

200

300

400

500

1990 1995 2001 2005 2010

Euthanasia Assisted Suicide Ending of Life Without Explicit Patient Request

Euthanasia Act Came Into Effect

5197 51465617

6861

9965

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

1990 1995 2001 2005 2010

N.º cases



RESULTS



RESULTS

n = 252

n = 251

n = 496

n = 270



RESULTS

n = 252

n = 251

n = 496

n = 270

In: THE LANCET • Published online June 17, 2003 • http://image.thelancet.com/extras/03art3297web.pdf


RESULTS

139 131

191

58 54

114

0

50

100

150

200

250

2001 2005 2010

0-64 65-79 > 80

1113

4

20

0

5

10

15

20

25

2001 2005 2010

0-64 65-79 > 80

Euthanasia and Physician

Assisted Suicide

Ending of Life Without Explicit Request

Intensified Alleviation Symptoms

AG

ES

EX

384

533

456536

721

553 558

948

303

0

100

200

300

400

500

600

700

800

900

1000

2001 2005 2010

0-64 65-79 > 80


Assisted Suicide



175 181

281

0

50

100

150

200

250

300

2001 2005 2010

Male Female

19

117

0

50

2001 2005 2010

Male Female

591

731

1101

100200300400500600700800900

10001100

2001 2005 2010

Male Female


RESULTS

280 269

415

45 3566

0

50

100

150

200

250

300

350

400

450

2001 2005 2010

C ancer C ardiovascular Desease Other

24

96

14

0

5

10

15

20

25

30

2001 2005 2010

Cancer Cardiovascular Desease Other


Assisted Suicide



Cau

se o

f D

eath

Typ

e o

f P

hysic

ian

989

1369

128 175 193

475314

640

709

0

200

400

600

800

1000

1200

1400

1600

2001 2005 2010

Cancer Cardiovascular Desease Other


Assisted Suicide



274 272

456

9 12 290

50100150200250300350400450500

2001 2005 2010

General Practitioner C linical Specialist Eldery C are Physician

20

6 5

4 4 6

0

50

2001 2005 2010


609686

403 410504

100200300400500600700800900

10001100

2001 2005 2010



RESULTS


Assisted Suicide



Dis

cu

ssio

nD

rug

s


Assisted Suicide



197

392

9 287 7

0

50

100

150

200

250

300

350

400

450

2005 2010

10

6

15

545

0

10

20

2005 2010

Discuss / Patient Discuss Relatives Discuss Physician No Discuss

760

411

596

994

554

962

613

400

500

600

700

800

900

1000

1100

2005 2010


5

1

5

4

1 1

7 7

3

00

1

2

3

4

5

6

7

8

2005 2010

384

853

71119

9471134

50

250

450

650

850

1050

1250

2005 2010

- Neuromuscular Relaxants – Barbiturates – Benzodiazepines / Opioids – Benzodiazepines – Opioids - Others

496

230

459

0

554346

0

0

100

200

300

400

500

2005 2010



CONCLUSION / FINDINGS

In 2010, of all deaths in the Netherlands, 2.8% were the result of euthanasia;

In 2005, of all deaths in the Netherlands, 1.7% were the result of euthanasia; Distribution of sex, age and diagnosis was stable between 1990 and 2010;

In 2010, 77% of all cases of euthanasia or PAS were reported to a review committee;

Ending of life without an explicit consent request in 2010 occurred less often than 2005, 2001, 1995, 1990.

Continuous deep sedation until death, occurred more frequently in 2010 than 2005;

All of deaths in 2010 were the result of the patient’s decision to stop eating and dinking to end of life;

In half of these cases the patient had made a euthanasia request that was not granted.



The most widely used drugs in ending of life were neuromuscular relaxants in E & PAS and barbiturates in end of life without explicit patient request;

Cancer is, in a general way, the most important cause of death;

General Practiniores were the professional medical speciality more envolved in all end-of-life pratices;



The most importante reasons for the physician to grant the euthanasia request that were mencioned most often in 2010 were:

- The wish of the patient

-No prospect of improvement

-No more options for treatment

-Loss of dignity

THANKS FOR THE ATTENTION


RESULTS


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