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Another argument in favour of uniform definitions ?

In June an Australian paper (www.theage.com) reported about the findings of a Belgian survey on the role of nurses in physician assisted deaths in Belgium. By using the wrong words they suggested a huge misbehaviour of Belgian doctors and nurses: 50% of all euthanasia-cases were non-voluntary, and 20% of all nurses had been involved in non-voluntary euthanasia cases.

The study was published as an original article in the Canadian Medical Association Journal. Reading the study it will be clear that what is defined by Belgian law as euthanasia is only 2% of all deaths, is by definition always voluntary (which is on request!)and considered to be a medical act. Bregje Onwuteaka, one of the authors of the survey, says in reaction to the assumptions in the paper (source EXIT Newsletter):
In the UK (and many countries that outlaw assistance at the end of life), there is a war of words over practices that are fiercely pushed into one classification or the other. Do UK hospices ever perform ‘euthanasia’? Of course not! (hands up in horror!) But they perform exactly the same actions that Belgian nurses are being pilloried for in the popular press.

When a patient is in the last few hours of life, opioids and sedative drugs are frequently and correctly increased (especially in hospices, that have less fear of legal reprisals) to reduce or eliminate suffering in the final moments. Generaly these drugs to not necessarily hasten the end. If they do, it is by a few hours perhaps, and it is thought of as double effect – a neat way of asserting that the intention was to relieve pain and suffering, not to hasten death.

In most cases in Belgium ‘without explicit request’ the drugs probably didn’t shorten life at all anyway. The study clearly states, ” . . . although physicians specified an intention to hasten death, opioids were often given in doses that were not higher than needed to relive the patient’s pain. This suggests that the practice of using life-ending drugs without an explicit patient request resembles more intensified pain alleviation with a ‘double effect,’ and that death was in many cases not hastened.” It is also noted that, “. . . the life-shortening effect of opioids is subject to speculation. Recent studies have shown that the actual effect on the end of life is prone to overestimation.”

The concern in Belgium is not over whether an unethical practice has occurred, but over whether nurses do not have appropriate guidelines to cover them legally. “. . . the nurses we surveyed who administered the life-ending drugs did not do so on their own initiative. Although the act was often performed without the physician being present, it was predominantly carried out on the physician’s orders and under his or her responsibility.” The study argues that professional guidelines are needed to help clarify nurses’ involvement in these practices lest they get caught in a vulnerable position when following a physician’s orders.

Another expert, Belgian professor Marc Englert fiercely rejected the wrong assumptions, caused by the words used in The Age. His reaction can be read here.

(comment RJ : of course uniformity in definitions is only helpfull if all parties concerned agree to use only those. And all parties include pro- and oppponents, media and politicians, doctors and lawmakers.)

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