- Email: [email protected]
Attitudes of Italian doctors to euthanasia and assisted suicide for terminally ill patients
five of 107 children from whom membrane cultures were obtained and who remained in the trial for follow-up, were found to have cerebral palsy (one additional child found to have cerebral palsy had no culture sample obtained at delivery). Two of these children had mild hemiplegia, one had moderate hemiplegia, two had diplegia and mild hemiplegia, and one had spastic quadriplegia and extrapyramidal involvement (mixed cerebral palsy). All assessments were done by a developmental paediatrician (NR) who was unaware of the bacteriological results. Membrane cultures for four of the five children with cerebral palsy grew isolates of coagulasenegative staphylococci, whereas only 26 of 102 children without cerebral palsy had positive cultures (p=0·02, two-sided Fisher’s exact test). Two of the four isolates from children with cerebral palsy were pure cultures of coagulase-negative staphylococci, and two were mixed cultures of coagulasenegative staphylococci and other bacteria. In the one case of cerebral palsy in which the chorioamniotic culture grew no microorganisms, a microscopic review of the culture discovered grape-like clusters of gram-positive cocci. Thus, coagulase-negative staphylococci may have been present at delivery in the membranes of this child as well. To find out whether potential confounding, such as birthweight, might account for this association, we assessed 16 suspected or known predictors of cerebral palsy. By univariate analysis, we found that five of these 16 possible risk factors had p values less than 0·10 (coagulase-negative staphylococci, p=0·02; birthweight, p=0·04; neonatal ventilation for ⭓20 days [an important correlate of serious neonatal illness], p<0·001; neonatal seizures or abnormal electroencephalogram, p=0·01; and non-vertex presentation, p=0·07). In a multivariate logistic regression model in which we controlled for these variables, the presence of coagulase-negative staphylococci in the chorioamniotic space remained highly significant (adjusted odds ratio 37·7 [95% CI 3·0–⬁]; p=0·003). The hypothesis we have generated—an association between coagulase-negative staphylococci and cerebral palsy—requires further testing, and large future studies may find significant associations between cerebal palsy and other species of bacteria. From these data, however, only coagulase-negative staphylococci were associated with cerebral palsy. Despite the fact that these bacteria are commonly thought of as contaminants, recent published studies have shown the substantial pathogenicity of their virulence factors, which include haemolysins, deoxyribonuclease, slime, and adhesins.4 If our findings are confirmed, a potentially treatable risk factor for cerebral palsy—a disease that has been largely resistant to medical interventions—may have been identified. We thank Anthony Montag, Robert Covert, David Yousefzadeh, Tamar Ben-Ami, Marguerite Herschel, William Meadow, Lynn Bentz, Jocelyn Kohn, M J Borg, and the resident physicians of the Chicago Lying-in Hospital. Funding was provided by the United Cerebral Palsy Research and Educational Foundation, Washington, DC, USA. 1 2
3
4
Nelson KB, Ellenberg JH. Predictors of low and very low birth weight and the relation of these to cerebral palsy. JAMA 1985; 254: 1473–79. Mittendorf R, Covert R, Boman J, Khoshnood B, Lee K-S, Siegler M. Is tocolytic magnesium sulphate associated with increased total paediatric mortality? Lancet 1997; 350: 1517–18. Hillier SL, Martius J, Krohn M, Kiviat N, Holmes KK, Eschenbach DA. A case-control study of chorioamnionic infection and histologic chorioamnionitis in prematurity. N Engl J Med 1988; 319: 972–78. Rupp ME, Archer GL. Coagulase-negative staphylococci: pathogens associated with medical progress. Clin Infect Dis 1994; 19: 231–45.
Department of Obstetrics and Gynecology (R Mittendorf MD, A Moawad MD), and Sections of Developmental Pediatrics and Neonatology, Department of Pediatrics (N Roizen MD, B Khoshnood MD, K-S Lee MD), Pritzker School of Medicine, University of Chicago, Chicago, IL, USA Correspondence to: Dr Robert Mittendorf, Department of Obstetrics and Gynecology, Chicago Lying-in Hospital, 5841 South Maryland Avenue, Chicago, IL 60637, USA (e-mail: [email protected])
1876
Attitudes of Italian doctors to euthanasia and assisted suicide for terminally ill patients L Grassi, M Agostini, K Magnani Among Italian hospital physicians and general practitioners, 17·9% endorsed euthanasia or assisted suicide for terminally ill patients and 79·4% endorsed withholding or withdrawal of treatment. Need for attention to quality of life and pain control also emerged.
Euthanasia and physician-assisted suicide have been the subject of intense worldwide debate.1,2 In Italy, euthanasia and physician-assisted suicide are banned by law and the code of medical practice. Nevertheless, in a 1996 study a third of Italian palliative-care physicians were in favour of euthanasia and 11·5% of those who received requests for enthanasia by their patients had complied at least once. 3 We did a study in Ferrara, north-east Italy, of a convenience sample of 148 physicians at the local university-based hospital (response rate 74·7%, mean age 36·9 years [SD 9·22]) and 182 general practitioners (GPs) working in the town (response rate 88·7%, mean age 42·34 years [5·86]). All respondents completed the euthanasia attitude questionnaire.4 Only a minority of the participants reported receiving requests for euthanasia (8·8%) or physician-assisted suicide (3·1%), whereas 29·8% had been asked by patients to withhold or withdraw life-sustaining treatments. The proportion who endorsed euthanasia and physician-assisted suicide was low (17·9%), whereas a higher proportion strongly or moderately agreed with the possibility of withholding or withdrawal of life-sustaining treatments (79·4%). Religious beliefs and the Hippocratic oath (59·9%) rather than fear of legal repercussions (27·7%) were the major deterrents to facilitating death. This result was more evident among GPs than hospital physicians (p=0·002). 67·5% of the sample agreed that more attention to quality-of-life issues and pain control would eliminate the need for euthanasia and physician-assisted suicide (75·1% of GPs, 58·1% of hospital physicians, p=0·005). Catholic physicians more firmly opposed euthanasia and physician-assisted suicide and withholding or withdrawal of treatment than non-Catholics (86·7 vs 50·7% and 20·0 vs 5·6%, respectively, p<0·01). No differences in response were found in relation to sex, specialty, and years since qualification. The principle of self-determination was regarded an important right for patients with an incurable disease (49·0%) and withholding or withdrawal of lifesustaining treatment was more acceptable than physicianassisted suicide, which was in turn more acceptable than euthanasia (71·5 vs 31·2 vs 26·7%; table). Furthermore, 88·6% of participants agreed to the use of a morphine drip to achieve pain control, even at risk of hastening the patient’s death.5 We thank the colleagues who participated in the study and D Doukas for use of the euthanasia attitude questionnaire. 1
Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician-assisted suicide: attitudes of oncology patients, oncologists, and the public. Lancet 1996; 347: 1805–10. 2 Ganzini L, Fenn DS, Lee MA, Henitz, Bloom JD. Attitudes of Oregon psychiatrists toward physician-assisted suicide. Am J Psychiatry 1996, 153: 1469–75. 3 Di Mola G, Borsellino P, Brunelli C, et al. Attitudes toward euthanasia of physician members of the Italian Society for Palliative Care. Ann Oncol 1996; 7: 907–11. 4 Doukas DJ, Waterhouse D, Gorenflo DW, Seid J. Attitudes of behaviors on physician-assisted death: a study of Michigan oncologists. J Clin Oncol 1995; 13: 1055–61.
THE LANCET • Vol 354 • November 27, 1999
Strongly Moderately Neither agree Moderately Strongly agree (%) agree (%) or disagree (%) disagree (%) disagree (%) It is acceptable to use a morphine drip to achieve pain control, even if it may hasten a patient’s death Oncologists should be allowed to withhold life-sustaining measures at the patient’s request Oncologists should be allowed to withdraw life-sustaining measures at the patient’s request More attention to quality-of-life concerns would eliminate the need for euthanasia More attention to pain control would eliminate the need for euthanasia The Hippocratic Oath would deter me from facilitating a patient’s death A person has the right to end his or her life if he or she has an incurable disease (eg, cancer) Most non-medical people would favour legislation allowing a terminally ill patient to ask an attending physician to help end his or her life I would favour legislation that allowed a terminally ill patient to ask an attending physician to help end his or her life When a person has a disease that cannot be cured, doctors should be allowed by law to end the patient’s life by some painless means, if the patient or his or her family request it Legislation permitting the practice of active euthanasia is needed Giving medication to a patient with the intent of allowing the patient to end his or her life is acceptable I would approve of ending a patient’s life if a board of doctors appointed by the court agreed that the patient could not be cured Giving instructions to a patient with the intent of allowing the patient to end his or her life is acceptable Oncologists are well trained to manage the care of terminally ill patients Physicians trained specially in the practice of euthanasia should be available to patients
60·7 46·6 41·0 37·2 34·0 43·1 29·7 14·0
27·9 25·9 24·8 25·4 34·3 15·3 19·3 22·4
4·0 6·8 8·3 12·7 11·7 15·7 11·9 21·8
2·8 5·6 9·5 14·6 14·2 11·3 15·3 19·3
4·6 15·1 16·5 10·2 5·9 14·5 23·9 22·4
13·9
17·3
10·2
17·6
40·9
13·7
16·8
8·2
18·6
42·7
12·1 8·6 4·0
14·6 8·6 7·1
11·1 8·3 4·9
11·5 18·8 15·7
50·8 55·7 68·3
9·0 4·6 7·7
10·2 17·0 10·2
9·3 34·1 30·5
20·4 30·7 13·5
51·1 13·6 38·2
Responses of hospital physicians and GPs to the euthanasia attitude questionnaire
Patients with terminal cancer are thought to be at high risk of committing suicide. In a population of 17 964 patients with terminal cancer cared for at home by 12 palliative-care teams, five patients committed suicide. We speculate that continuing care made up by symptomatic treatment and psychosocial support given to these patients may reduce the risk.
Cancer Institute, which was notified of any case of suicide, defined as a self-induced injury or drug overdose resulting in death. 17 964 patients (9200 men) aged 61 years or less (33%), 62–72 years (35%), or 73 years or more (32%) were enrolled and five cases of suicide (0·027%) were recorded (figure). Of these, two were women (breast cancer, melanoma) and three were men (bladder, lung, and unknown primary cancer site). Mean age was 65 years (range 50–76) and the duration of home care by the palliative-care team was a median 30 days. Two patients jumped out of a window, two shot themselves, and one took an overdose of morphine. Patients were usually seen every day, which makes the underestimation of suicide unlikely even if this occurred by drug overdose. Our findings are similar to a study carried out on 72 633 patients with terminal cancer admitted to 43 palliative-care units over 5 years, which reported 21 suicides (0·029%).3 It is not possible to determine whether the frequency of suicide differs with respect to those patients who did not use home palliative-care programmes because we have not included a control group for ethical reasons. Rates of suicide in the general population resident in the same area (Lombardy) yield standardised mortality ratios (SMR=observed suicides/expected suicides) of 15 for men (3/0·2) and 33 for women (2/0·06). The expected number of suicides was estimated by multiplying age-specific and sex-specific suicide
Patients with terminal cancer are thought to be at high risk of suicide due to pain, helplessness, and exhaustion,1 or because further treatment or contact with the health-care system is not provided;2 however, no studies have been made on this population for this particular purpose. From September, 1985, to December, 1997, we evaluated suicides in all patients with terminal cancer cared for at home by 12 associated palliative-care teams organised in Milan and its provinces by non-profit Floriani Foundation and the Italian League against Cancer. All patients had died by Dec 31, 1997. Criteria for admission to our home palliative-care programme are patient’s consent, incurable cancer, poor performance status, symptoms requiring palliative treatment, and at least one family member living with the patient. Each team is made up of doctors, nurses, volunteers, social workers, and psychologists providing continuing care to allow patients to spend the end of their lives at home. All the teams had similar training in palliative care and were used to treating and dealing with dying patients. The study was organised by the palliative-care team of the Milan National
Number of patients cared for at home who died by Dec 31, 1997
5
Quill TE, Dresser R, Brock DW. The rule of double effect: a critique of its role in end of life decision making. N Engl J Med 1997; 337: 1768–71.
Clinica Psichiatrica Università di Ferrara, Arcispedale S Anna, Corso Giovecca 203, 44100 Ferrara, Italy (L Grassi MD, M Agostini MD , K Magnani PhD) Correspondence to: Dr L Grassi (e-mail: [email protected])
Suicide among patients with cancer cared for at home by palliative-care teams Carla Ripamonti, Antonio Filiberti, Amadio Totis, Franco De Conno, Marcello Tamburini
THE LANCET • Vol 354 • November 27, 1999
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3
4
Nelson KB, Ellenberg JH. Predictors of low and very low birth weight and the relation of these to cerebral palsy. JAMA 1985; 254: 1473–79. Mittendorf R, Covert R, Boman J, Khoshnood B, Lee K-S, Siegler M. Is tocolytic magnesium sulphate associated with increased total paediatric mortality? Lancet 1997; 350: 1517–18. Hillier SL, Martius J, Krohn M, Kiviat N, Holmes KK, Eschenbach DA. A case-control study of chorioamnionic infection and histologic chorioamnionitis in prematurity. N Engl J Med 1988; 319: 972–78. Rupp ME, Archer GL. Coagulase-negative staphylococci: pathogens associated with medical progress. Clin Infect Dis 1994; 19: 231–45.
Department of Obstetrics and Gynecology (R Mittendorf MD, A Moawad MD), and Sections of Developmental Pediatrics and Neonatology, Department of Pediatrics (N Roizen MD, B Khoshnood MD, K-S Lee MD), Pritzker School of Medicine, University of Chicago, Chicago, IL, USA Correspondence to: Dr Robert Mittendorf, Department of Obstetrics and Gynecology, Chicago Lying-in Hospital, 5841 South Maryland Avenue, Chicago, IL 60637, USA (e-mail: [email protected])
1876
Attitudes of Italian doctors to euthanasia and assisted suicide for terminally ill patients L Grassi, M Agostini, K Magnani Among Italian hospital physicians and general practitioners, 17·9% endorsed euthanasia or assisted suicide for terminally ill patients and 79·4% endorsed withholding or withdrawal of treatment. Need for attention to quality of life and pain control also emerged.
Euthanasia and physician-assisted suicide have been the subject of intense worldwide debate.1,2 In Italy, euthanasia and physician-assisted suicide are banned by law and the code of medical practice. Nevertheless, in a 1996 study a third of Italian palliative-care physicians were in favour of euthanasia and 11·5% of those who received requests for enthanasia by their patients had complied at least once. 3 We did a study in Ferrara, north-east Italy, of a convenience sample of 148 physicians at the local university-based hospital (response rate 74·7%, mean age 36·9 years [SD 9·22]) and 182 general practitioners (GPs) working in the town (response rate 88·7%, mean age 42·34 years [5·86]). All respondents completed the euthanasia attitude questionnaire.4 Only a minority of the participants reported receiving requests for euthanasia (8·8%) or physician-assisted suicide (3·1%), whereas 29·8% had been asked by patients to withhold or withdraw life-sustaining treatments. The proportion who endorsed euthanasia and physician-assisted suicide was low (17·9%), whereas a higher proportion strongly or moderately agreed with the possibility of withholding or withdrawal of life-sustaining treatments (79·4%). Religious beliefs and the Hippocratic oath (59·9%) rather than fear of legal repercussions (27·7%) were the major deterrents to facilitating death. This result was more evident among GPs than hospital physicians (p=0·002). 67·5% of the sample agreed that more attention to quality-of-life issues and pain control would eliminate the need for euthanasia and physician-assisted suicide (75·1% of GPs, 58·1% of hospital physicians, p=0·005). Catholic physicians more firmly opposed euthanasia and physician-assisted suicide and withholding or withdrawal of treatment than non-Catholics (86·7 vs 50·7% and 20·0 vs 5·6%, respectively, p<0·01). No differences in response were found in relation to sex, specialty, and years since qualification. The principle of self-determination was regarded an important right for patients with an incurable disease (49·0%) and withholding or withdrawal of lifesustaining treatment was more acceptable than physicianassisted suicide, which was in turn more acceptable than euthanasia (71·5 vs 31·2 vs 26·7%; table). Furthermore, 88·6% of participants agreed to the use of a morphine drip to achieve pain control, even at risk of hastening the patient’s death.5 We thank the colleagues who participated in the study and D Doukas for use of the euthanasia attitude questionnaire. 1
Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician-assisted suicide: attitudes of oncology patients, oncologists, and the public. Lancet 1996; 347: 1805–10. 2 Ganzini L, Fenn DS, Lee MA, Henitz, Bloom JD. Attitudes of Oregon psychiatrists toward physician-assisted suicide. Am J Psychiatry 1996, 153: 1469–75. 3 Di Mola G, Borsellino P, Brunelli C, et al. Attitudes toward euthanasia of physician members of the Italian Society for Palliative Care. Ann Oncol 1996; 7: 907–11. 4 Doukas DJ, Waterhouse D, Gorenflo DW, Seid J. Attitudes of behaviors on physician-assisted death: a study of Michigan oncologists. J Clin Oncol 1995; 13: 1055–61.
THE LANCET • Vol 354 • November 27, 1999
Strongly Moderately Neither agree Moderately Strongly agree (%) agree (%) or disagree (%) disagree (%) disagree (%) It is acceptable to use a morphine drip to achieve pain control, even if it may hasten a patient’s death Oncologists should be allowed to withhold life-sustaining measures at the patient’s request Oncologists should be allowed to withdraw life-sustaining measures at the patient’s request More attention to quality-of-life concerns would eliminate the need for euthanasia More attention to pain control would eliminate the need for euthanasia The Hippocratic Oath would deter me from facilitating a patient’s death A person has the right to end his or her life if he or she has an incurable disease (eg, cancer) Most non-medical people would favour legislation allowing a terminally ill patient to ask an attending physician to help end his or her life I would favour legislation that allowed a terminally ill patient to ask an attending physician to help end his or her life When a person has a disease that cannot be cured, doctors should be allowed by law to end the patient’s life by some painless means, if the patient or his or her family request it Legislation permitting the practice of active euthanasia is needed Giving medication to a patient with the intent of allowing the patient to end his or her life is acceptable I would approve of ending a patient’s life if a board of doctors appointed by the court agreed that the patient could not be cured Giving instructions to a patient with the intent of allowing the patient to end his or her life is acceptable Oncologists are well trained to manage the care of terminally ill patients Physicians trained specially in the practice of euthanasia should be available to patients
60·7 46·6 41·0 37·2 34·0 43·1 29·7 14·0
27·9 25·9 24·8 25·4 34·3 15·3 19·3 22·4
4·0 6·8 8·3 12·7 11·7 15·7 11·9 21·8
2·8 5·6 9·5 14·6 14·2 11·3 15·3 19·3
4·6 15·1 16·5 10·2 5·9 14·5 23·9 22·4
13·9
17·3
10·2
17·6
40·9
13·7
16·8
8·2
18·6
42·7
12·1 8·6 4·0
14·6 8·6 7·1
11·1 8·3 4·9
11·5 18·8 15·7
50·8 55·7 68·3
9·0 4·6 7·7
10·2 17·0 10·2
9·3 34·1 30·5
20·4 30·7 13·5
51·1 13·6 38·2
Responses of hospital physicians and GPs to the euthanasia attitude questionnaire
Patients with terminal cancer are thought to be at high risk of committing suicide. In a population of 17 964 patients with terminal cancer cared for at home by 12 palliative-care teams, five patients committed suicide. We speculate that continuing care made up by symptomatic treatment and psychosocial support given to these patients may reduce the risk.
Cancer Institute, which was notified of any case of suicide, defined as a self-induced injury or drug overdose resulting in death. 17 964 patients (9200 men) aged 61 years or less (33%), 62–72 years (35%), or 73 years or more (32%) were enrolled and five cases of suicide (0·027%) were recorded (figure). Of these, two were women (breast cancer, melanoma) and three were men (bladder, lung, and unknown primary cancer site). Mean age was 65 years (range 50–76) and the duration of home care by the palliative-care team was a median 30 days. Two patients jumped out of a window, two shot themselves, and one took an overdose of morphine. Patients were usually seen every day, which makes the underestimation of suicide unlikely even if this occurred by drug overdose. Our findings are similar to a study carried out on 72 633 patients with terminal cancer admitted to 43 palliative-care units over 5 years, which reported 21 suicides (0·029%).3 It is not possible to determine whether the frequency of suicide differs with respect to those patients who did not use home palliative-care programmes because we have not included a control group for ethical reasons. Rates of suicide in the general population resident in the same area (Lombardy) yield standardised mortality ratios (SMR=observed suicides/expected suicides) of 15 for men (3/0·2) and 33 for women (2/0·06). The expected number of suicides was estimated by multiplying age-specific and sex-specific suicide
Patients with terminal cancer are thought to be at high risk of suicide due to pain, helplessness, and exhaustion,1 or because further treatment or contact with the health-care system is not provided;2 however, no studies have been made on this population for this particular purpose. From September, 1985, to December, 1997, we evaluated suicides in all patients with terminal cancer cared for at home by 12 associated palliative-care teams organised in Milan and its provinces by non-profit Floriani Foundation and the Italian League against Cancer. All patients had died by Dec 31, 1997. Criteria for admission to our home palliative-care programme are patient’s consent, incurable cancer, poor performance status, symptoms requiring palliative treatment, and at least one family member living with the patient. Each team is made up of doctors, nurses, volunteers, social workers, and psychologists providing continuing care to allow patients to spend the end of their lives at home. All the teams had similar training in palliative care and were used to treating and dealing with dying patients. The study was organised by the palliative-care team of the Milan National
Number of patients cared for at home who died by Dec 31, 1997
5
Quill TE, Dresser R, Brock DW. The rule of double effect: a critique of its role in end of life decision making. N Engl J Med 1997; 337: 1768–71.
Clinica Psichiatrica Università di Ferrara, Arcispedale S Anna, Corso Giovecca 203, 44100 Ferrara, Italy (L Grassi MD, M Agostini MD , K Magnani PhD) Correspondence to: Dr L Grassi (e-mail: [email protected])
Suicide among patients with cancer cared for at home by palliative-care teams Carla Ripamonti, Antonio Filiberti, Amadio Totis, Franco De Conno, Marcello Tamburini
THE LANCET • Vol 354 • November 27, 1999
1877