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Facing a request for assisted death – views of Finnish physicians, a mixed method study

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This study reveals new and more in-depth knowledge about physicians’ actions when facing a request for assisted death in a country where euthanasia and PAS are not legal. Physicians have adopted various ways to deal with a request for assisted death, as they also have different attitudes toward euthanasia and PAS.

In our study, only 13% fully agreed with the statement “I could assist a patient in a suicide”. In previous studies, willingness to perform euthanasia or PAS among physicians has varied widely from 2 to 16% in Germany, 8% in the United States, and 30% in Italy [30,31,32]. A recent questionnaire study from Sweden showed that 33% of respondents were willing to prescribe the drugs needed to perform assisted suicide in 2020 [5]. On the other hand, in the Netherlands and Belgium, where assisted death has been legal for decades, 86% and 81% of physicians could imagine a circumstance in which they might participate in the practice of euthanasia or PAS [3].

Most participants agreed that euthanasia should be accepted only in difficult physical symptoms in the end stage of a disease. Difficult physical symptoms have been one of the reasons for euthanasia or PAS in many countries [30, 31]. Others include for example, loss of function, dependency or loss of independence, deterioration, loss of dignity, and hopelessness [33, 34]. In a study from Oregon, as many as 57% of patients reported loss of independence as a reason for requests for PAS [33]. In our study, only 3% fully agreed with the statement “If euthanasia would be legalized in Finland, life turning into an unbearable burden, should also be accepted as a reason for euthanasia”. Males and physicians who had faced these requests agreed fully or partly agreed more often (16% in both groups) with this in our study. This question aimed to ask whether the responder thinks that euthanasia with unbearable suffering without unbearable physical symptoms would be an acceptable reason for euthanasia. In many countries ‘unbearable suffering’ is a criterion for euthanasia, but only when it occurs together with a disease. The complexity of unbearable suffering is reflected by the ongoing debates regarding whether euthanasia and assisted suicide should be permitted for psychiatric disorders. In some countries, including Belgium and the Netherlands, it is legal to perform assisted death based on psychiatric disorders [30]. A systematic review from 2020 showed that articles providing ethical reasoning and opinions in favor of or against assisted death based on psychiatric disorders were evenly distributed [35].

In our study, male and young physicians thought more often that they could assist in a suicide, which probably reflects the overall more positive attitude in these groups regarding practicing PAS and euthanasia [4, 5, 32]. In addition, if a physician had faced a request for assisted death, they were more likely to have positive attitudes toward euthanasia and PAS. No previous studies were found to support this finding.

The amount of experience in the care of dying patients was associated with less agreement with assisting in a suicide and with the general view that physicians should not assist in a suicide. In a study from Germany, physicians with special qualifications in palliative care were more reluctant to hasten a patient’s death through euthanasia or PAS [30], which is in line with our findings. It is also known from previous studies, that physicians with the most experience with end-of-life care and palliative care have been most reluctant toward euthanasia and PAS [36, 37], and this finding is again repeated in this study. The reasons behind this have not been profoundly studied. However, it can be argued that knowledge and experience with palliative and end-of-life care can provide more options to take care of the patient. It might also be better understood among physicians with experience in dealing with end-of-life issues that a patient’s wish to hasten death does not always imply a genuine wish to die [38,39,40]. It might be a result of overwhelming physical, psychological, social, and existential suffering, all of which have an impact on the patient’s sense of self, dignity, and meaning in life [38,39,40].

This study showed that physicians face the request for assisted death in their everyday practice even if it is not legal in Finland. However, the requests were not very common, as only 16% of participants reported having been asked for euthanasia or assistance in suicide. In a study from Sweden, half of the physicians who participated in that study had heard their patients expressing a wish to die, but only a few had asked for euthanasia or assisted suicide [21]. In an older study from England, as many as 45% of physicians who responded to a questionnaire, reported having been asked for euthanasia [20].

Physicians reported diverse ways of responding to the request and actions they took when meeting the request for assisted death. There is relatively little research about requests for assisted death when it is not legal. It is known that the patient´s wish for euthanasia could persist for at least one year despite the wish being declined [41]. Additionally, a small qualitative study from the Netherlands found that the wish to die is not abandoned, although the request has been refused [42]. Based on these results, ongoing discussions and suggestions for practice are needed when these requests are faced in countries where assisted death is not a legal option or when the request is rejected in the countries allowing assisted death.

In the results of the qualitative data of this study, many physicians expressed that knowledge of the possibility of palliative sedation at the end of life could comfort patients frightened of suffering at the end of life when assisted death is not a legal possibility. There is only a limited amount of knowledge on the relationship between assisted death and palliative sedation. In a study from Switzerland, continuous deep sedation was not considered an alternative to assisted suicide, but temporary or intermittent sedation was sometimes introduced in response to a request for assisted suicide [43].

In this study, the request was also sometimes seen as a possibility to enhance the care and find the underlying reasons for the death wish. The results also showed that physicians were seeking alternatives to alleviate suffering, including improving symptom management, maintaining hope and a sense of meaning in life, and providing an appropriate place of care and adequate support for the patient. In a Swedish study, some respondents answered that a request for euthanasia might express wishes for the alleviation of symptoms or wider communication: after talking, these requests disappear [21].

Ignoring the request was one way of dealing with the request in our study. However, ignoring the request for assisted death could indicate that the reasons behind the death wish are ignored [41]. Therefore, it could be stated that refusal without further discussion or support is not the optimal way to act when meeting the request for assisted death.

Some physicians responded to comply or partly comply with the request, e.g. describing drugs or recommending contacting a Swiss clinic. In Scandinavia, euthanasia or assistance in suicide is very rarely reported by physicians [21, 44,45,46]. This is understandable, as euthanasia is under the criminal code in all Scandinavian countries.

Some fears of whether one´s actions had hastened the patient´s death were reported in this study. Hastening a patient’s death or a fear of doing so when alleviating severe symptoms or withdrawal of treatment, is by far more difficult and ethically challenging question, and is sometimes confused with euthanasia or PAS [47]. A large multinational study performed in 2005 found that there was general approval for alleviating symptoms with possible life-shortening treatment among physicians [48]. Similar findings were discovered in a European study from six different countries, where 57–95% of physicians were willing to intensify the drug therapy to alleviate pain and/or other symptoms, although they considered that there was a probability or certainty that this would shorten a patient’s life [49].

Some of the physicians expressed mixed feelings about what would be the right way to act when facing a request for assisted death. This calls for recommendations or guidelines on how to act when meeting the request. Only a few recommendations have been published where practical guidance on how to respond to the request for assisted death is provided and some of them apply merely in countries where assisted death is possible to practice [50,51,52]. The most important recommendation for health care professionals in these articles is to try to understand the meaning behind the request and to be able to face the difficult emotions the request evokes both in a patient and in the professionals [50,51,52].

Strengths and limitations

The study population is a large and representative sample of Finnish physicians [53], although the response rate was rather low, and possible nonresponse bias must be taken into account. The sampling, data collection, and analysis process were reported in detail, which increases the reliability of the study. The sample included physicians with different backgrounds, such as different specialties and amounts of experience. Therefore, it can be assumed that the study population gave a large and versatile view of physicians’ attitudes toward assisted death and how they act when facing a request for assisted death. Furthermore, dependability was strengthened by presenting the figure of all the categories (Fig. 1), and authenticity was strengthened by providing authentic citations of the data. It should also be noted that the researchers constantly discussed the analysis throughout the study. Confirmability was strengthened by focusing on the manifest content during the analysis when it can be assumed that the results would represent the views of the physicians [28].

There are also several limitations in this study. Nonresponse bias might have affected the results, but the number of respondents was, however, substantial. Furthermore, there was no possibility to return the qualitative findings to the physicians for comments or corrections [24]. The questionnaire used in this study is the same that has been used in a series of surveys and to maintain comparability, the questions and statements were similar to the previous ones [4]. There are clear differences in the ethical and practical issues between euthanasia and PAS, but in the open-ended question and some other parts of our results, these two methods of assisted death were combined. This should be taken into account when interpreting our results. However, the request for assisted death may be presented without a specific definition of PAS or euthanasia and both are unlegalized in Finland. Thus, we do believe the answers of the respondents reflect the overall views of the Finnish physicians concerning assisted death and experiences when facing the request for this.

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Health Canada approves updated Moderna COVID-19 vaccine

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TORONTO – Health Canada has authorized Moderna’s updated COVID-19 vaccine that protects against currently circulating variants of the virus.

The mRNA vaccine, called Spikevax, has been reformulated to target the KP.2 subvariant of Omicron.

It will replace the previous version of the vaccine that was released a year ago, which targeted the XBB.1.5 subvariant of Omicron.

Health Canada recently asked provinces and territories to get rid of their older COVID-19 vaccines to ensure the most current vaccine will be used during this fall’s respiratory virus season.

Health Canada is also reviewing two other updated COVID-19 vaccines but has not yet authorized them.

They are Pfizer’s Comirnaty, which is also an mRNA vaccine, as well as Novavax’s protein-based vaccine.

This report by The Canadian Press was first published Sept. 17, 2024.

Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.

The Canadian Press. All rights reserved.

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These people say they got listeria after drinking recalled plant-based milks

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TORONTO – Sanniah Jabeen holds a sonogram of the unborn baby she lost after contracting listeria last December. Beneath, it says “love at first sight.”

Jabeen says she believes she and her baby were poisoned by a listeria outbreak linked to some plant-based milks and wants answers. An investigation continues into the recall declared July 8 of several Silk and Great Value plant-based beverages.

“I don’t even have the words. I’m still processing that,” Jabeen says of her loss. She was 18 weeks pregnant when she went into preterm labour.

The first infection linked to the recall was traced back to August 2023. One year later on Aug. 12, 2024, the Public Health Agency of Canada said three people had died and 20 were infected.

The number of cases is likely much higher, says Lawrence Goodridge, Canada Research Chair in foodborne pathogen dynamics at the University of Guelph: “For every person known, generally speaking, there’s typically 20 to 25 or maybe 30 people that are unknown.”

The case count has remained unchanged over the last month, but the Public Health Agency of Canada says it won’t declare the outbreak over until early October because of listeria’s 70-day incubation period and the reporting delays that accompany it.

Danone Canada’s head of communications said in an email Wednesday that the company is still investigating the “root cause” of the outbreak, which has been linked to a production line at a Pickering, Ont., packaging facility.

Pregnant people, adults over 60, and those with weakened immune systems are most at risk of becoming sick with severe listeriosis. If the infection spreads to an unborn baby, Health Canada says it can cause miscarriage, stillbirth, premature birth or life-threatening illness in a newborn.

The Canadian Press spoke to 10 people, from the parents of a toddler to an 89-year-old senior, who say they became sick with listeria after drinking from cartons of plant-based milk stamped with the recalled product code. Here’s a look at some of their experiences.

Sanniah Jabeen, 32, Toronto

Jabeen says she regularly drank Silk oat and almond milk in smoothies while pregnant, and began vomiting seven times a day and shivering at night in December 2023. She had “the worst headache of (her) life” when she went to the emergency room on Dec. 15.

“I just wasn’t functioning like a normal human being,” Jabeen says.

Told she was dehydrated, Jabeen was given fluids and a blood test and sent home. Four days later, she returned to hospital.

“They told me that since you’re 18 weeks, there’s nothing you can do to save your baby,” says Jabeen, who moved to Toronto from Pakistan five years ago.

Jabeen later learned she had listeriosis and an autopsy revealed her baby was infected, too.

“It broke my heart to read that report because I was just imagining my baby drinking poisoned amniotic fluid inside of me. The womb is a place where your baby is supposed to be the safest,” Jabeen said.

Jabeen’s case is likely not included in PHAC’s count. Jabeen says she was called by Health Canada and asked what dairy and fresh produce she ate – foods more commonly associated with listeria – but not asked about plant-based beverages.

She’s pregnant again, and is due in several months. At first, she was scared to eat, not knowing what caused the infection during her last pregnancy.

“Ever since I learned about the almond, oat milk situation, I’ve been feeling a bit better knowing that it wasn’t something that I did. It was something else that caused it. It wasn’t my fault,” Jabeen said.

She’s since joined a proposed class action lawsuit launched by LPC Avocates against the manufacturers and sellers of Silk and Great Value plant-based beverages. The lawsuit has not yet been certified by a judge.

Natalie Grant and her seven year-old daughter, Bowmanville, Ont.

Natalie Grant says she was in a hospital waiting room when she saw a television news report about the recall. She wondered if the dark chocolate almond milk her daughter drank daily was contaminated.

She had brought the girl to hospital because she was vomiting every half hour, constantly on the toilet with diarrhea, and had severe pain in her abdomen.

“I’m definitely thinking that this is a pretty solid chance that she’s got listeria at this point because I knew she had all the symptoms,” Grant says of seeing the news report.

Once her daughter could hold fluids, they went home and Grant cross-checked the recalled product code – 7825 – with the one on her carton. They matched.

“I called the emerg and I said I’m pretty confident she’s been exposed,” Grant said. She was told to return to the hospital if her daughter’s symptoms worsened. An hour and a half later, her fever spiked, the vomiting returned, her face flushed and her energy plummeted.

Grant says they were sent to a hospital in Ajax, Ont. and stayed two weeks while her daughter received antibiotics four times a day until she was discharged July 23.

“Knowing that my little one was just so affected and how it affected us as a family alone, there’s a bitterness left behind,” Grant said. She’s also joined the proposed class action.

Thelma Feldman, 89, Toronto

Thelma Feldman says she regularly taught yoga to friends in her condo building before getting sickened by listeria on July 2. Now, she has a walker and her body aches. She has headaches and digestive problems.

“I’m kind of depressed,” she says.

“It’s caused me a lot of physical and emotional pain.”

Much of the early days of her illness are a blur. She knows she boarded an ambulance with profuse diarrhea on July 2 and spent five days at North York General Hospital. Afterwards, she remembers Health Canada officials entering her apartment and removing Silk almond milk from her fridge, and volunteers from a community organization giving her sponge baths.

“At my age, 89, I’m not a kid anymore and healing takes longer,” Feldman says.

“I don’t even feel like being with people. I just sit at home.”

Jasmine Jiles and three-year-old Max, Kahnawake Mohawk Territory, Que.

Jasmine Jiles says her three-year-old son Max came down with flu-like symptoms and cradled his ears in what she interpreted as a sign of pain, like the one pounding in her own head, around early July.

When Jiles heard about the recall soon after, she called Danone Canada, the plant-based milk manufacturer, to find out if their Silk coconut milk was in the contaminated batch. It was, she says.

“My son is very small, he’s very young, so I asked what we do in terms of overall monitoring and she said someone from the company would get in touch within 24 to 48 hours,” Jiles says from a First Nations reserve near Montreal.

“I never got a call back. I never got an email”

At home, her son’s fever broke after three days, but gas pains stuck with him, she says. It took a couple weeks for him to get back to normal.

“In hindsight, I should have taken him (to the hospital) but we just tried to see if we could nurse him at home because wait times are pretty extreme,” Jiles says, “and I don’t have child care at the moment.”

Joseph Desmond, 50, Sydney, N.S.

Joseph Desmond says he suffered a seizure and fell off his sofa on July 9. He went to the emergency room, where they ran an electroencephalogram (EEG) test, and then returned home. Within hours, he had a second seizure and went back to hospital.

His third seizure happened the next morning while walking to the nurse’s station.

In severe cases of listeriosis, bacteria can spread to the central nervous system and cause seizures, according to Health Canada.

“The last two months have really been a nightmare,” says Desmond, who has joined the proposed lawsuit.

When he returned home from the hospital, his daughter took a carton of Silk dark chocolate almond milk out of the fridge and asked if he had heard about the recall. By that point, Desmond says he was on his second two-litre carton after finishing the first in June.

“It was pretty scary. Terrifying. I honestly thought I was going to die.”

Cheryl McCombe, 63, Haliburton, Ont.

The morning after suffering a second episode of vomiting, feverish sweats and diarrhea in the middle of the night in early July, Cheryl McCombe scrolled through the news on her phone and came across the recall.

A few years earlier, McCombe says she started drinking plant-based milks because it seemed like a healthier choice to splash in her morning coffee. On June 30, she bought two cartons of Silk cashew almond milk.

“It was on the (recall) list. I thought, ‘Oh my God, I got listeria,’” McCombe says. She called her doctor’s office and visited an urgent care clinic hoping to get tested and confirm her suspicion, but she says, “I was basically shut down at the door.”

Public Health Ontario does not recommend listeria testing for infected individuals with mild symptoms unless they are at risk of developing severe illness, such as people who are immunocompromised, elderly, pregnant or newborn.

“No wonder they couldn’t connect the dots,” she adds, referencing that it took close to a year for public health officials to find the source of the outbreak.

“I am a woman in my 60s and sometimes these signs are of, you know, when you’re vomiting and things like that, it can be a sign in women of a bigger issue,” McCombe says. She was seeking confirmation that wasn’t the case.

Disappointed, with her stomach still feeling off, she says she decided to boost her gut health with probiotics. After a couple weeks she started to feel like herself.

But since then, McCombe says, “I’m back on Kawartha Dairy cream in my coffee.”

This report by The Canadian Press was first published Sept. 16, 2024.

Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.

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B.C. mayors seek ‘immediate action’ from federal government on mental health crisis

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VANCOUVER – Mayors and other leaders from several British Columbia communities say the provincial and federal governments need to take “immediate action” to tackle mental health and public safety issues that have reached crisis levels.

Vancouver Mayor Ken Sim says it’s become “abundantly clear” that mental health and addiction issues and public safety have caused crises that are “gripping” Vancouver, and he and other politicians, First Nations leaders and law enforcement officials are pleading for federal and provincial help.

In a letter to Prime Minister Justin Trudeau and Premier David Eby, mayors say there are “three critical fronts” that require action including “mandatory care” for people with severe mental health and addiction issues.

The letter says senior governments also need to bring in “meaningful bail reform” for repeat offenders, and the federal government must improve policing at Metro Vancouver ports to stop illicit drugs from coming in and stolen vehicles from being exported.

Sim says the “current system” has failed British Columbians, and the number of people dealing with severe mental health and addiction issues due to lack of proper care has “reached a critical point.”

Vancouver Police Chief Adam Palmer says repeat violent offenders are too often released on bail due to a “revolving door of justice,” and a new approach is needed to deal with mentally ill people who “pose a serious and immediate danger to themselves and others.”

This report by The Canadian Press was first published Sept. 16, 2024

The Canadian Press. All rights reserved.

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