BUGNON . O DESC Réa LYON Décembre 2006

1. BUGNON . O DESC Réa LYON Décembre 2006

2. ευθανασ'ια “good death” or the facilitation of a good death • to cause death • intentionally • desire to promote the best interest • using the most gentle means an “end of life without pain, comforted, peaceful, experiencing dignity and respect as well as closeness to family”

3. La dérive … • Darwin “The Origin of Species” 1859 • Herbert Spencer “Social Darwinism” • The eugenics movement • (forced) sterilization, quarantine, abortion, and even “euthanasia” of those thought to carry undesirable genetic material • Alfred Ploetz “racial hygiene” 1895 • the “Aryan” race • lawyer Karl Binding / psychiatrist Alfred Hoche The National Socialist Physicians’ League 1929 6% of the entire German medical profession

4. La dérive … “Law for the Prevention of Hereditarily Diseased Progeny” 1933 “The Nuremberg Laws” 1935

5. La dérive … By 1942, nearly one-half of all physicians in Germany were Nazi party members

6. La dérive … the T4 Program (“Tiergartenstrasse 4” in Berlin) a “mercy death” to patients judged “incurably sick by medical examination” Hitler 1939 6000 children 200000 adults

7. La dérive … The “euthanasia” program

8. sur le banc des accusés … ? the “Physicians’ Trial” in Nuremberg (1946–1947) 20 Nazi physicians and biomedical scientists accused 7 acquitted

10. In Belgium • Law on euthanasia : effect on 23 sept 2002 • « action on the part of a third person intented to end the life of someone who has requested it »

11. Euthanasia is no longer a criminal offense provided that … Patient • Older than 18, legally competent, conscious at the time of the request • Serious and incurable condition with constant suffering and unbearable physical or psychological pain which cannot be alleviated with medical or other treatment

12. Request • Volontary, carefully considered, repeated, without external pressure • Written, dated, signed (possible help by someone without material benefit in the patiet’s death) • Revocable at any time

13. Unbearable suffering ?? general weariness no acceptable alternative treatment family or society coercion

14. Physician • Fully informs patient about his health status, life expectancy, possible therapeutic options including palliatiative care • Agrees with the patient that there is no other reasonable option • Checks for real unbearable suffering, and repeats discussions to ensure that the request is not transient • Consults another physician • Discusses the request with care-team and family if wanted by patient • Is not obliged to perform a asked euthanasia provided the medical chart is handed to another physician chosen by the patient

15. Advance directives • Any individual may write a declaration in anticipation of a state in which euthanasia may be an option, but in which he would no longer be able or competent to make a decision • May designate impartial trusted individuals to inform the phycisian about the presence of an advance directive • May be made at any time provided it carries the signatures of two witnesses • 5 years validity

16. Control process • 1st document : details of the patient, physician, consultations related to the request • 2nd document : more details on the reasons for and the nature of the request, and the method of euthanasia used • National Comission of Control and Evaluation (8 physicians (50% Pr) , 4 Pr of law, 4 involved in care of the terminally ill) • Doubts : 1st document opened and case referred to the coroner

17. 2 years later … • 500 cases euthanasia • 0,2 % total death • 83% flemish – 17% french • The most prominent reasons for the request : “pointless suffering” “deterioration or loss of dignity” “weakness or tiredness” • 1 advance directive and unconscious • 64% > 60 years • 83% cancer – 13% neuromuscular • 48% specialist – 32.5% general practitioner – 19.5% specialist in palliative care • 54% in hospital – 41% at home • 81.5% barbiturates – 10% midazolam

18. In ICU … • Patient often comatose, confused, too weak to organize his toughts no request from patient : - is withdrawning or withelding of care in patients with no hope of a meaningful survival illegal ? • Must we continue care ad infinitum even when acknowledged as futile by all involved ?

19. In ICU … • Advance directive and surrogate nominated … • Is surrogate able to understand the complexities of the situation, the options available and to take the good decision at a time of heightened emotional stress and anxiety ? • mechanical ventilation in pneumonia ??

20. Euthanasia = to achieve a good death Dignified, Peaceful, Pain-free, in presence of family and friends • may be helped by withdrawning and withholding care if adherence to bioethical principles • Are intensivists illegal and do they need formal, signed approval if • effective communication and open discussion of all options available • increasing doses of sedatives and analgesic agents at the right time are performed ??? Should legislation recognize that ?

21. Merci pour votre attention

22. Références … End-of-life practice in Belgium and the new euthanasia law Intensice Care Med (2006) Jean-Louis Vincent

23. Euthanasia and physician-assisted suicide in The Netherlands