End-of-life care

From Wikipedia, the free encyclopedia

End-of-life care refers to health care provided in the time leading up to a person's death. End-of-life care can be provided in the hours, days, or months before a person dies and encompasses care and support for a person's mental and emotional needs, physical comfort, spiritual needs, and practical tasks.

EoLC is most commonly provided at home, in the hospital, or in a long-term care facility with care being provided by family members, nurses, social workers, physicians, and other support staff. Facilities may also have palliative or hospice care teams that will provide end-of-life care services. Decisions about end-of-life care are often informed by medical, financial and ethical considerations.

In most advanced countries, medical spending on people in the last twelve months of life makes up roughly 10% of total aggregate medical spending, while those in the last three years of life can cost up to 25%.

Medical

Advanced care planning

Advances in medicine in the last few decades have provided us with an increasing number of options to extend a person's life and highlighted the importance of ensuring that an individual's preferences and values for end-of-life care are honored. Advanced care planning is the process by which a person of any age is able to provide their preferences and ensure that their future medical treatment aligns with their personal values and life goals. It is typically a continual process, with ongoing discussions about a patient's current prognosis and conditions as well as conversations about medical dilemmas and options. A person will typically have these conversations with their doctor and ultimately record their preferences in an advance healthcare directive. An advance healthcare directive is a legal document that either documents a person's decisions about desired treatment or indicates who a person has entrusted to make their care decisions for them. The two main types of advanced directives are a living will and durable power of attorney for healthcare. A living will includes a person's decisions regarding their future care, a majority of which address resuscitation and life support but may also delve into a patients’ preferences regarding hospitalization, pain control, and specific treatments that they may undergo in the future. The living will will typically take effect when a patient is terminally ill with low chances of recovery. A durable power of attorney for healthcare allows a person to appoint another individual to make healthcare decisions for them under a specified set of circumstances. Combined directives, such as the "Five Wishes", that include components of both the living will and durable power of attorney for healthcare, are being increasingly utilized. Advanced care planning often includes preferences for CPR initiation, nutrition (tube feeding), as well as decisions about the use of machines to keep a person breathing, or support their heart or kidneys. Many studies have reported benefits to patients who complete advanced care planning, specifically noting the improved patient and surrogate satisfaction with communication and decreased clinician distress. However, there is a notable lack of empirical data about what outcome improvements patients experience, as there are considerable discrepancies in what constitutes as advanced care planning and heterogeneity in the outcomes measured. Advanced care planning remains an underutilized tool for patients. Researchers have published data to support the use of new relationship-based and supported decision making models that can increase the use and maximize the benefit of advanced care planning.

End-of-life care conversations

End-of-life care conversations are part of the treatment planning process for terminally ill patients requiring palliative care involving a discussion of a patient's prognosis, specification of goals of care, and individualized treatment planning. Current studies suggest that many patients prioritize proper symptom management, avoidance of suffering, and care that aligns with ethical and cultural standards. Specific conversations can include discussions about cardiopulmonary resuscitation (ideally occurring before the active dying phase as to not force the conversation during a medical crisis/emergency), place of death, organ donation, and cultural/religious traditions. As there are many factors involved in the end-of-life care decision-making process, the attitudes and perspectives of patients and families may vary. For example, family members may differ over whether life extension or life quality is the main goal of treatment. As it can be challenging for families in the grieving process to make timely decisions that respect the patient's wishes and values, having an established advanced care directive in place can prevent over-treatment, under-treatment, or further complications in treatment management.

Patients and families may also struggle to grasp the inevitability of death, and the differing risks and effects of medical and non-medical interventions available for end-of-life care. A systematic literature review reviewing the frequency of end-of-life care conversations between COPD patients and clinicians found that conversations regarding end-of-life care often occur when a patient has advanced stage disease and occur at a low frequency. To prevent interventions that are not in accordance with the patient's wishes, end-of-life care conversations and advanced care directives can allow for the care they desire, as well as help prevent confusion and strain for family members.

In the case of critically ill babies, parents are able to participate more in decision making if they are presented with options to be discussed rather than recommendations by the doctor. Utilizing this style of communication also leads to less conflict with doctors and might help the parents cope better with the eventual outcomes.

Signs of dying

The National Cancer Institute in the United States (US) advises that the presence of some of the following signs may indicate that death is approaching:

• Drowsiness, increased sleep, and/or unresponsiveness (caused by changes in the patient's metabolism).
• Confusion about time, place, and/or identity of loved ones; restlessness; visions of people and places that are not present; pulling at bed linen or clothing (caused in part by changes in the patient's metabolism).
• Decreased socialization and withdrawal (caused by decreased oxygen to the brain, decreased blood flow, and mental preparation for dying).
• Changes in breathing (indicate neurologic compromise and impending death) and accumulation of upper airway secretions (resulting in crackling and gurgling breath sounds) 
• Decreased need for food and fluids, and loss of appetite (caused by the body's need to conserve energy and its decreasing ability to use food and fluids properly).
• Decreased oral intake and impaired swallowing (caused by general physical weakness and metabolic disturbances, including but not limited to hypercalcemia) 
• Loss of bladder or bowel control (caused by the relaxing of muscles in the pelvic area).
• Darkened urine or decreased amount of urine (caused by slowing of kidney function and/or decreased fluid intake).
• Skin becoming cool to the touch, particularly the hands and feet; skin may become bluish in color, especially on the underside of the body (caused by decreased circulation to the extremities).
• Rattling or gurgling sounds while breathing, which may be loud (death rattle); breathing that is irregular and shallow; decreased number of breaths per minute; breathing that alternates between rapid and slow (caused by congestion from decreased fluid consumption, a buildup of waste products in the body, and/or a decrease in circulation to the organs).
• Turning of the head toward a light source (caused by decreasing vision).
• Increased difficulty controlling pain (caused by progression of the disease).
• Involuntary movements (called myoclonus)
• Increased heart rate
• Hypertension followed by hypotension
• Loss of reflexes in the legs and arms

Symptoms management

The following are some of the most common potential problems that can arise in the last days and hours of a patient's life:

Pain

Typically controlled with opioids, like morphine, fentanyl, hydromorphone or, in the United Kingdom, diamorphine. High doses of opioids can cause respiratory depression, and this risk increases with concomitant use of alcohol and other sedatives. Careful use of opioids is important to improve the patient's quality of life while avoiding overdoses.

Agitation

Delirium, terminal anguish, restlessness (e.g. thrashing, plucking, or twitching). Typically controlled using clonazepam or midazolam, antipsychotics such as haloperidol or levomepromazine may also be used instead of, or concomitantly with benzodiazepines. Symptoms may also sometimes be alleviated by rehydration, which may reduce the effects of some toxic drug metabolites.

Respiratory tract secretions

Saliva and other fluids can accumulate in the oropharynx and upper airways when patients become too weak to clear their throats, leading to a characteristic gurgling or rattle-like sound ("death rattle"). While apparently not painful for the patient, the association of this symptom with impending death can create fear and uncertainty for those at the bedside. The secretions may be controlled using drugs such as hyoscine butylbromide, glycopyrronium, or atropine. Rattle may not be controllable if caused by deeper fluid accumulation in the bronchi or the lungs, such as occurs with pneumonia or some tumours.

Nausea and vomiting

Typically controlled using haloperidol, metoclopramide, ondansetron, cyclizine; or other anti-emetics.

Dyspnea (breathlessness)

Typically controlled with opioids, like morphine, fentanyl or, in the United Kingdom, diamorphine

Constipation

Low food intake and opioid use can lead to constipation which can then result in agitation, pain, and delirium. Laxatives and stool softeners are used to prevent constipation. In patients with constipation, the dose of laxatives will be increased to relieve symptoms. Methylnaltrexone is approved to treat constipation due to opioid use.

Other symptoms that may occur, and may be mitigated to some extent, include cough, fatigue, fever, and in some cases bleeding.

Medication administration

Subcutaneous injections are one preferred means of delivery when it has become difficult for patients to swallow or to take pills orally, and if repeated medication is needed, a syringe driver (or infusion pump in the US) is often likely to be used, to deliver a steady low dose of medication. In some settings, such as the home or hospice, sublingual routes of administration may be used for most prescriptions and medications.

Another means of medication delivery, available for use when the oral route is compromised, is a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route. The catheter was developed to make rectal access more practical and provide a way to deliver and retain liquid formulations in the distal rectum so that health practitioners can leverage the established benefits of rectal administration. Its small flexible silicone shaft allows the device to be placed safely and remain comfortably in the rectum for repeated administration of medications or liquids. The catheter has a small lumen, allowing for small flush volumes to get medication to the rectum. Small volumes of medications (under 15mL) improve comfort by not stimulating the defecation response of the rectum and can increase the overall absorption of a given dose by decreasing pooling of medication and migration of medication into more proximal areas of the rectum where absorption can be less effective.

Integrated pathways

Integrated care pathways are an organizational tool used by healthcare professionals to clearly define the roles of each team-member and coordinate how and when care will be provided. These pathways are utilized to ensure best practices are being utilized for end-of-life care, such as evidence-based and accepted health care protocols, and to list the required features of care for a specific diagnosis or clinical problem. Many institutions have a predetermined pathway for end of life care, and clinicians should be aware of and make use of these plans when possible. In the United Kingdom, end-of-life care pathways are based on the Liverpool Care Pathway. Originally developed to provide evidence based care to dying cancer patients, this pathway has been adapted and used for a variety of chronic conditions at clinics in the UK and internationally. Despite its increasing popularity, the 2016 Cochrane Review, which only analyzed one trial, showed limited evidence in the form of high-quality randomized clinical trials to measure the effectiveness of end-of-life care pathways on clinical outcomes, physical outcomes, and emotional/psychological outcomes. The BEACON Project group developed an integrated care pathway entitled the Comfort Care Order Set, which delineates care for the last days of life in either a hospice or acute care inpatient setting. This order set was implemented and evaluated in a multisite system throughout six United States Veterans Affairs Medical Centers, and the study found increased orders for opioid medication post-pathway implementation, as well as more orders for antipsychotic medications, more patients undergoing palliative care consultations, more advance directives, and increased sublingual drug administration. The intervention did not, however, decrease the proportion of deaths that occurred in an ICU setting or the utilization of restraints around death.

Home-based end-of-life care

While not possible for every person needing care, surveys of the general public suggest most people would prefer to die at home. In the period from 2003 to 2017, the number of deaths at home in the United States increased from 23.8% to 30.7%, while the number of deaths in the hospital decreased from 39.7% to 29.8%. Home-based end-of-life care may be delivered in a number of ways, including by an extension of a primary care practice, by a palliative care practice, and by home care agencies such as Hospice. High-certainty evidence indicates that implementation of home-based end-of-life care programs increases the number of adults who will die at home and slightly improves their satisfaction at a one-month follow-up. There is low-certainty evidence that there may be very little or no difference in satisfaction of the person needing care for longer term (6 months). The number of people who are admitted to hospital during an end-of-life care program is not known. In addition, the impact of home-based end-of-life care on caregivers, healthcare staff, and health service costs is not clear, however, there is weak evidence to suggest that this intervention may reduce health care costs by a small amount.

Disparities in end-of-life care

Not all groups in society have good access to end-of-life care. A systematic review conducted in 2021 investigated the end of life care experiences of people with severe mental illness, including those with schizophrenia, bipolar disorder, and major depressive disorder. The research found that individuals with a severe mental illness were unlikely to receive the most appropriate end of life care. The review recommended that there needs to be close partnerships and communication between mental health and end of life care systems, and these teams need to find ways to support people to die where they choose. More training, support and supervision needs to be available for professionals working in end of life care; this could also decrease prejudice and stigma against individuals with severe mental illness at the end of life, notably in those who are homeless. In addition, studies have shown that minority patients face several additional barriers to receiving quality end-of-life care. Minority patients are prevented from accessing care at an equitable rate for a variety of reasons including: individual discrimination from caregivers, cultural insensitivity, racial economic disparities, as well as medical mistrust.

Non-medical

Family and friends

Family members are often uncertain as to what they should be doing when a person is dying. Many gentle, familiar daily tasks, such as combing hair, putting lotion on delicate skin, and holding hands, are comforting and provide a meaningful method of communicating love to a dying person.

Family members may be suffering emotionally due to the impending death. Their own fear of death may affect their behavior. They may feel guilty about past events in their relationship with the dying person or feel that they have been neglectful. These common emotions can result in tension, fights between family members over decisions, worsened care, and sometimes (in what medical professionals call the "Daughter from California syndrome") a long-absent family member arrives while a patient is dying to demand inappropriately aggressive care.

Family members may also be coping with unrelated problems, such as physical or mental illness, emotional and relationship issues, or legal difficulties. These problems can limit their ability to be involved, civil, helpful, or present.

Spirituality and religion

Spirituality is thought to be of increased importance to an individual's wellbeing during a terminal illness or toward the end-of-life. Pastoral/spiritual care has a particular significance in end of life care, and is considered an essential part of palliative care by the WHO. In palliative care, responsibility for spiritual care is shared by the whole team, with leadership given by specialist practitioners such as pastoral care workers. The palliative care approach to spiritual care may, however, be transferred to other contexts and to individual practice.

Spiritual, cultural, and religious beliefs may influence or guide patient preferences regarding end-of-life care. Healthcare providers caring for patients at the end of life can engage family members and encourage conversations about spiritual practices to better address the different needs of diverse patient populations. Studies have shown that people who identify as religious also report higher levels of well-being. Religion has also been shown to be inversely correlated with depression and suicide. While religion provides some benefits to patients, there is some evidence of increased anxiety and other negative outcomes in some studies. While spirituality has been associated with less aggressive end-of-life care, religion has been associated with an increased desire for aggressive care in some patients. Despite these varied outcomes, spiritual and religious care remains an important aspect of care for patients. Studies have shown that barriers to providing adequate spiritual and religious care include a lack of cultural understanding, limited time, and a lack of formal training or experience.

Many hospitals, nursing homes, and hospice centers have chaplains who provide spiritual support and grief counseling to patients and families of all religious and cultural backgrounds.

Ageism

The World Health Organization defines ageism as "the stereotypes (how we think), prejudice (how we feel) and discrimination (how we act) towards others or ourselves based on age." A systematic review in 2017 showed that negative attitudes amongst nurses towards older individuals were related to the characteristics of the older adults and their demands. This review also highlighted how nurses who had difficulty giving care to their older patients perceived them as "weak, disabled, inflexible, and lacking cognitive or mental ability". Another systematic review considering structural and individual-level effects of ageism found that ageism led to significantly worse health outcomes in 95.5% of the studies and 74.0% of the 1,159 ageism-health associations examined. Studies have also shown that one’s own perception of aging and internalized ageism negatively impacts their health. In the same systematic review, they included this factor as part of their research. It was concluded that 93.4% of their total 142 associations about self-perceptions of aging show significant associations between ageism and worse health.

Attitudes of healthcare professionals

End-of-life care is an interdisciplinary endeavor involving physicians, nurses, physical therapists, occupational therapists, pharmacists and social workers. Depending on the facility and level of care needed, the composition of the interprofessional team can vary. Health professional attitudes about end-of-life care depend in part on the provider's role in the care team.

Physicians generally have favorable attitudes towards Advance Directives, which are a key facet of end-of-life care. Medical doctors who have more experience and training in end-of-life care are more likely to cite comfort in having end-of-life-care discussions with patients. Those physicians who have more exposure to end-of-life care also have a higher likelihood of involving nurses in their decision-making process.

A systematic review assessing end-of-life conversations between heart failure patients and healthcare professionals evaluated physician attitudes and preferences towards end-of-life care conversations. The study found that physicians found difficulty initiating end-of-life conversations with their heart failure patients, due to physician apprehension over inducing anxiety in patients, the uncertainty in a patient's prognosis, and physicians awaiting patient cues to initiate end-of-life care conversations.

Although physicians make official decisions about end-of-life care, nurses spend more time with patients and often know more about patient desires and concerns. In a Dutch national survey study of attitudes of nursing staff about involvement in medical end-of-life decisions, 64% of respondents thought patients preferred talking with nurses than physicians and 75% desired to be involved in end-of-life decision making.

By country

Canada

In 2012, Statistics Canada's General Social Survey on Caregiving and care receiving found that 13% of Canadians (3.7 million) aged 15 and older reported that at some point in their lives they had provided end-of-life or palliative care to a family member or friend. For those in their 50s and 60s, the percentage was higher, with about 20% reporting having provided palliative care to a family member or friend. Women were also more likely to have provided palliative care over their lifetimes, with 16% of women reporting having done so, compared with 10% of men. These caregivers helped terminally ill family members or friends with personal or medical care, food preparation, managing finances or providing transportation to and from medical appointments.

United Kingdom

End of life care has been identified by the UK Department of Health as an area where quality of care has previously been "very variable," and which has not had a high profile in the NHS and social care. To address this, a national end of life care programme was established in 2004 to identify and propagate best practice, and a national strategy document published in 2008. The Scottish Government has also published a national strategy.

In 2006 just over half a million people died in England, about 99% of them adults over the age of 18, and almost two-thirds adults over the age of 75. About three-quarters of deaths could be considered "predictable" and followed a period of chronic illness – for example heart disease, cancer, stroke, or dementia. In all, 58% of deaths occurred in an NHS hospital, 18% at home, 17% in residential care homes (most commonly people over the age of 85), and about 4% in hospices. However, a majority of people would prefer to die at home or in a hospice, and according to one survey less than 5% would rather die in hospital. A key aim of the strategy therefore is to reduce the needs for dying patients to have to go to hospital and/or to have to stay there; and to improve provision for support and palliative care in the community to make this possible. One study estimated that 40% of the patients who had died in hospital had not had medical needs that required them to be there.

In 2015 and 2010, the UK ranked highest globally in a study of end-of-life care. The 2015 study said "Its ranking is due to comprehensive national policies, the extensive integration of palliative care into the National Health Service, a strong hospice movement, and deep community engagement on the issue." The studies were carried out by the Economist Intelligence Unit and commissioned by the Lien Foundation, a Singaporean philanthropic organisation.

The 2015 National Institute for Health and Care Excellence guidelines introduced religion and spirituality among the factors which physicians shall take into account for assessing palliative care needs. In 2016, the UK Minister of Health signed a document which declared people "should have access to personalised care which focuses on the preferences, beliefs and spiritual needs of the individual." As of 2017, more than 47% of the 500,000 deaths in the UK occurred in hospitals.

In 2021 the National Palliative and End of Life Care Partnership published their six ambitions for 2021–26. These include fair access to end of life care for everyone regardless of who they are, where they live or their circumstances, and the need to maximise comfort and wellbeing. Informed and timely conversations are also highlighted.

Research funded by the UK's National Institute for Health and Care Research (NIHR) has addressed these areas of need. Examples highlight inequalities faced by several groups and offers recommendations. These include the need for close partnership between services caring for people with severe mental illness, improved understanding of barriers faced by Gypsy, Traveller and Roma communities, the provision of flexible palliative care services for children from ethnic minorities or deprived areas.

Other research suggests that giving nurses and pharmacists easier access to electronic patient records about prescribing could help people manage their symptoms at home. A named professional to support and guide patients and carers through the healthcare system could also improve the experience of care at home at the end of life. A synthesised review looking at palliative care in the UK created a resource showing which services were available and grouped them according to their intended purpose and benefit to the patient. They also stated that currently in the UK palliative services are only available to patients with a timeline to death, usually 12 months or less. They found these timelines to often be inaccurate and created barriers to patients accessing appropriate services. They call for a more holistic approach to end of life care which is not restricted by arbitrary timelines.

United States

Further information: Hospice care in the United States

As of 2019, physician-assisted dying is legal in eight states (California, Colorado, Hawaii, Maine, New Jersey, Oregon, Vermont, Washington) and Washington D.C.

Spending on those in the last twelve months accounts for 8.5% of total aggregate medical spending in the United States.

When considering only those aged 65 and older, estimates show that about 27% of Medicare's annual $327 billion budget ($88 billion) in 2006 goes to care for patients in their final year of life. For the over-65s, between 1992 and 1996, spending on those in their last year of life represented 22% of all medical spending, 18% of all non-Medicare spending, and 25 percent of all Medicaid spending for the poor. These percentages appears to be falling over time, as in 2008, 16.8% of all medical spending on the over 65s went on those in their last year of life.

Predicting death is difficult, which has affected estimates of spending in the last year of life; when controlling for spending on patients who were predicted as likely to die, Medicare spending was estimated at 5% of the total.

Assisted suicide

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Assisted_suicide

Current status of assisted suicide around the world:

  Physician-assisted suicide is legal

  Legalized by court ruling, but not legislated or regulated

  Physician-assisted suicide is illegal

Assisted suicide is suicide undertaken with the aid of another person. The term usually refers to physician-assisted suicide (PAS), which is suicide that is assisted by a physician or another healthcare provider. Once it is determined that the person's situation qualifies under the physician-assisted suicide laws for that location, the physician's assistance is usually limited to writing a prescription for a lethal dose of drugs.

In many jurisdictions, helping a person die by suicide is a crime. People who support legalizing physician-assisted suicide want the people who assist in a voluntary death to be exempt from criminal prosecution for manslaughter or similar crimes. Physician-assisted suicide is legal in some countries, under certain circumstances, including Austria, Belgium, Canada, Germany, Luxembourg, the Netherlands, New Zealand, Portugal, Spain, Switzerland, parts of the United States and all six states of Australia. The constitutional courts of Colombia, Germany and Italy legalized assisted suicide, but their governments have not legislated or regulated the practice yet.

In most of those states or countries, to qualify for legal assistance, individuals who seek a physician-assisted suicide must meet certain criteria, including: having a terminal illness, proving they are of sound mind, voluntarily and repeatedly expressing their wish to die, and taking the specified, lethal dose by their own hand. The laws vary in scope from place to place. In the United States, PAS is limited to those who have a prognosis of six months or less to live. In other countries such as Germany, Canada, Switzerland, Spain, Italy, Austria, Belgium and the Netherlands, a terminal diagnosis is not a requirement and voluntary euthanasia is additionally allowed.

Terminology

Secobarbital is one of the most commonly prescribed drugs for physician-assisted suicide in the United States.

Suicide is the act of killing oneself. Assisted suicide is when another person materially helps an individual person die by suicide, such as providing tools or equipment, while physician-assisted suicide involves a physician (doctor) "knowingly and intentionally providing a person with the knowledge or means or both required to commit suicide, including counseling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs".

Assisted suicide is contrasted to euthanasia, sometimes referred to as mercy killing, where the person dying does not directly bring about their own death, but is killed in order to stop the person from experiencing further suffering. Euthanasia can occur with or without consent, and can be classified as voluntary, non-voluntary or involuntary. Killing a person who is suffering and who consents is called voluntary euthanasia. This is currently legal in some regions. If the person is unable to provide consent it is referred to as non-voluntary euthanasia. Killing a person who does not want to die, or who is capable of giving consent and whose consent has not been solicited, is the crime of involuntary euthanasia, and is regarded as murder.

Right to die is the belief that people have a right to die, either through various forms of suicide, euthanasia, or refusing life-saving medical treatment.

Suicidism can be defined as "the quality or state of being suicidal" or as "... an oppressive system (stemming from non-suicidal perspectives) functioning at the normative, discursive, medical, legal, social, political, economic, and epistemic levels in which suicidal people experience multiple forms of injustice and violence..."

Assisted dying versus assisted suicide

Some advocates for assisted suicide strongly oppose the use of "assisted suicide" and "suicide" when referring to physician-assisted suicide, and prefer phrases like "medical aid in dying" or "assisted dying". The motivation for this is to distance the debate from the suicides commonly performed by those not terminally ill and not eligible for assistance where it is legal. They feel those cases have negatively impacted the word "suicide" to the point that it should not be used to refer to the practice of a physician prescribing lethal drugs to a person with a terminal illness. However, in certain jurisdictions, like Canada, "aid in dying" does not require a person's natural death to be reasonably foreseeable in order to be eligible for MAiD. Moreover, the term "assisted dying" is also used to refer to other practices like voluntary euthanasia and terminal sedation.

Physician-assisted suicide

Support

Arguments for

Arguments in support of assisted death include respect for patient autonomy, equal treatment of terminally ill patients on and off life support, compassion, personal liberty, transparency and ethics of responsibility. When death is imminent (half a year or less) patients can choose to have assisted death as a medical option to shorten what the person perceives to be an unbearable dying process.

Death With Dignity is coined as the United States national leader in end of life advocacy and policy reform. The organization has been advocating for physician-assisted suicide and euthanasia since 1994. 

Pain is mostly not reported as the primary motivation for seeking physician-assisted suicide in the United States; the three most frequently mentioned end‐of‐life concerns reported by Oregon residents who took advantage of the Death With Dignity Act in 2015 were: decreasing ability to participate in activities that made life enjoyable (96.2%), loss of autonomy (92.4%), and loss of dignity (75.4%).

Oregon statistics

A study of hospice nurses and social workers in Oregon reported that symptoms of pain, depression, anxiety, extreme air hunger and fear of the process of dying were more pronounced among hospice patients who did not request a lethal prescription for barbiturates, the drug used for physician-assisted death.

A Journal of Palliative Medicine report on patterns of hospice use noted that Oregon was in both the highest quartile of hospice use and the lowest quartile of potentially concerning patterns of hospice use. A similar trend was found in Vermont, where aid-in-dying (AiD) was authorized in 2013.

In February 2016, Oregon released a report on its 2015 numbers. In 2015, there were 218 people in the state who were approved and received the lethal drugs to end their own life. Of that 218, 132 terminally ill patients ultimately decided to ingest drugs, resulting in their death. According to the state of Oregon Public Health Division's survey, the majority of the participants, 78%, were 65 years of age or older and predominantly white, 93.1%. 72% of the terminally ill patients who opted for ending their own lives had been diagnosed with some form of cancer. In the state of Oregon's 2015 survey, they asked the terminally ill who were participating in medical aid in dying, what their biggest end-of-life concerns were: 96.2% of those people mentioned the loss of the ability to participate in activities that once made them enjoy life, 92.4% mentioned the loss of autonomy, or the independence of their own thoughts or actions, and 75.4% stated loss of their dignity.

Washington State statistics

An increasing trend in deaths caused by ingesting lethal doses of medications prescribed by physicians was also noted in Washington: from 64 deaths in 2009 to 202 deaths in 2015. Among the deceased, 72% had terminal cancer and 8% had neurodegenerative diseases (including ALS).

U.S. polls

Polls conducted by Gallup dating back to 1947 posit the question, "When a person has a disease that cannot be cured, do you think doctors should be allowed to end the patient's life by some painless means if the patient and his family request it?" show support for the practice increasing from 37% in 1947 to a plateau of approximately 75% lasting from approximately 1990 to 2005. When the polling question was modified as such so the question posits "severe pain" as opposed to an incurable disease, "legalization" as opposed to generally allowing doctors, and "patient suicide" rather than physician-administered voluntary euthanasia, public support was substantially lower, by approximately 10% to 15%.

A poll conducted by National Journal and Regence Foundation found that both Oregonians and Washingtonians were more familiar with the terminology "end-of-life care" than the rest of the country and residents of both states are slightly more aware of the terms palliative and hospice care.

A survey from the Journal of Palliative Medicine found that family caregivers of patients who chose assisted death were more likely to find positive meaning in caring for a patient and were more prepared for accepting a patient's death than the family caregivers of patients who did not request assisted death.

Safeguards

Many current assisted death laws contain provisions that are intended to provide oversight and investigative processes to prevent abuse. This includes eligibility and qualification processes, mandatory state reporting by the medical team, and medical board oversight. In Oregon and other states, two doctors and two witnesses must assert that a person's request for a lethal prescription was not coerced or under undue influence.

These safeguards include proving one's residency and eligibility. The patient must meet with two physicians and they must confirm the diagnoses before one can continue the procedure; in some cases, they do include a psychiatric evaluation as well to determine whether or not the patient is making this decision on their own. The next steps are two oral requests, a waiting period of a minimum of 15 days before making the next request. A written request which must be witnessed by two different people, one of which cannot be a family member, and then another waiting period by the patient's doctor in which they say whether they are eligible for the drugs or not ("Death with Dignity").

The debate about whether these safeguards work is debated between opponents and proponents.

A 1996 survey of Oregon emergency physicians found that "Only 37% indicated that the Oregon initiative has enough safeguards to protect vulnerable persons." 83% agreed that patients "Might feel pressure because of burden to others" and 70% agreed that patients "Might feel pressure because of financial concerns".

Religious stances in favor

Unitarian Universalism

According to a 1988 General Resolution, "Unitarian Universalists advocate the right to self-determination in dying, and the release from civil or criminal penalties of those who, under proper safeguards, act to honor the right of terminally ill patients to select the time of their own deaths".

Opposition

Medical ethics

Hippocratic Oath

Some doctors remind that physician-assisted suicide is contrary to the Hippocratic Oath, which is the oath historically taken by physicians. It states "I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan.". The original oath however has been modified many times and, contrary to popular belief, is not required by most modern medical schools, nor confers any legal obligations on individuals who choose to take it. There are also procedures forbidden by the Hippocratic Oath which are in common practice today, such as abortion and execution.

Declaration of Geneva

The Declaration of Geneva is a revision of the Hippocratic Oath, first drafted in 1948 by the World Medical Association in response to forced (involuntary) euthanasia, eugenics and other medical crimes performed in Nazi Germany. It contains, "I will maintain the utmost respect for human life."

International Code of Medical Ethics

The International Code of Medical Ethics, last revised in 2006, includes "A physician shall always bear in mind the obligation to respect human life" in the section "Duties of physicians to patients".

Statement of Marbella

The Statement of Marbella was adopted by the 44th World Medical Assembly in Marbella, Spain, in 1992. It provides that "physician-assisted suicide, like voluntary euthanasia, is unethical and must be condemned by the medical profession."

Concerns of expansion to people with chronic disorders

Main article: Euthanasia and the slippery slope

A concern present among health care professionals who are opposed to PAS, are the detrimental effects that the procedure can have with regard to vulnerable populations. This argument is known as the "slippery slope". This argument encompasses the apprehension that once PAS is initiated for the terminally ill it will progress to other vulnerable communities, namely disabled people, and may begin to be used by those who feel less worthy based on their demographic or socioeconomic status. In addition, vulnerable populations are more at risk of untimely deaths because, "patients might be subjected to PAS without their genuine consent".

Religious stances in opposition

Catholicism

The Roman Catholic Church acknowledges the fact that moral decisions regarding a person's life must be made according to one's own conscience and faith. Catholic tradition has said that one's concern for the suffering of another is not a sufficient reason to decide whether it is appropriate to act upon voluntary euthanasia. According to the Catechism of the Catholic Church, "God is the creator and author of all life." In this belief system God created human life, therefore God is the judge of when to end life. From the Roman Catholic Church's perspective, deliberately ending one's life or the life of another is morally wrong and defies the Catholic doctrine. Furthermore, ending one's life deprives that person and his or her loved ones of the time left in life and causes grief and sorrow for those left behind.

Pope Francis is the current dominant figure of the Catholic Church. He affirms that death is a glorious event and should not be decided for by anyone other than God. Pope Francis insinuates that defending life means defending its sacredness. The Roman Catholic Church teaches its followers that the act of euthanasia is unacceptable because it is perceived as a sin, as it goes against one of the Ten Commandments. As implied by the sixth commandment, "Thou shalt not kill (You shall not kill)," the act of assisted suicide contradicts the dignity of human life as well as the respect one has for God. Additionally, the Roman Catholic Church recommends that terminally ill patients should receive palliative care, which deals with physical pain while treating psychological and spiritual suffering as well, instead of physician-assisted suicide.

Judaism

While preservation of life is one of the greatest values in Judaism, there are instances of suicide and assisted suicide appearing in the Bible and Rabbinic literature. The medieval authorities debate the legitimacy of those measures and in what limited circumstances they might apply. The conclusion of the majority of later rabbinic authorities, and accepted normative practice within Judaism, is that suicide and assisted suicide can not be sanctioned even for a terminal patient in intractable pain.

The Church of Jesus Christ of Latter-day Saints

The Church of Jesus Christ of Latter-day Saints (LDS Church) is against assisted suicide and euthanasia, and anyone who takes part in either is regarded as having violated the commandments of God. However the church recognizes that when a person is in the final stages of terminal illness there may be difficult decisions to be taken. The church states that "When dying becomes inevitable, death should be looked upon as a blessing and a purposeful part of an eternal existence. Members should not feel obligated to extend mortal life by means that are unreasonable".

Neutrality

There have been calls for organisations representing medical professionals to take a neutral stance on PAS, rather than a position of opposition. The reasoning is that this supposedly would better reflect the views of medical professionals and that of wider society, and prevent those bodies from exerting undue influence over the debate.

The UK Royal College of Nursing voted in July 2009 to move to a neutral position on PAS.

The California Medical Association dropped its long-standing opposition in 2015 during the debate over whether a Physician Assisted Suicide bill should be introduced there, prompted in part by cancer sufferer Brittany Maynard. The California End of Life Option Act was signed into law later that year.

In December 2017, the Massachusetts Medical Society (MMS) voted to repeal their opposition to physician-assisted suicide and adopt a position of neutrality.

In October 2018, the American Academy of Family Physicians (AAFP) voted to adopt a position of neutrality from one of opposition. This is contrary to the position taken by the American Medical Association (AMA), which opposes it.

In January 2019 the British Royal College of Physicians announced it would adopt a position of neutrality until two-thirds of its members think it should either support or oppose the legalization of PAS.

In September 2021, the largest doctors union in the United Kingdom, the British Medical Association, adopted a neutral stance towards a change in the law on assisted dying, replacing their position of opposition which had been in place since 2006.

American Medical Association Code of Ethics

The American Medical Association (AMA) opposes physician-assisted suicide. In response to the ongoing debate about PAS, the AMA has issued guidance for both those who support and oppose physician-assisted suicide. The AMA Code of Ethics Opinion 5.7 reads that "Physician-assisted suicide is fundamentally incompatible with the physician's role as healer" and that it would be "difficult or impossible to control, and would pose serious societal risks" but does not explicitly prohibit the practice. In the AMA Code of Ethics Opinion 1.1.7, which the AMA states "articulates the thoughtful moral basis for those who support assisted suicide", it is written that outside of specific situations in which physicians have clear obligations, such as emergency care or respect for civil rights, "physicians may be able to act (or refrain from acting) in accordance with the dictates of their conscience without violating their professional obligations."

Attitudes of healthcare professionals

It is widely believed that physicians should play a significant role, usually expressed as "gatekeeper", in the process of assisted suicide and voluntary euthanasia (as evident in the name "physician-assisted suicide"), often putting them at the forefront of the issue. Decades of opinion research show that physicians in the US and several European countries are less supportive of the legalization of PAS than the general public. In the US, although "about two-thirds of the American public since the 1970s" have supported legalization, surveys of physicians "rarely show as much as half supporting a move". However, physician and other healthcare professional opinions vary widely on the issue of physician-assisted suicide, as shown in the following tables.

Study	Population	Willing to Assist PAS		Not Willing to Assist PAS
Canadian Medical Association, 2011	Canadian Medical Association (n=2,125)	16%		44%
Cohen, 1994 (NEJM)	Washington state doctors (n=938)	40%		49%
Lee, 1996 (NEJM)	Oregon state doctors (n=2,761)	46%		31%

Study	Population	In favor of PAS being legal		Not in favor of PAS being legal
Medscape Ethics Report, 2014	U.S.-based doctors	54%		31%
Seale, 2009	United Kingdom physicians (n=3,733)	35%		62.2%
Cohen, 1994 (NEJM)	Washington state doctors (n=938)	53%		39%

A 2019 survey of US physicians found that 60% of physicians answered 'yes' to the question "Should PAS be legalized in your state?" The survey discovered that physicians are concerned about a possible "slippery slope". 30% agreed that "PAS/AID would lead to the legalization of euthanasia" and 46% agreed that "Health insurance companies would cover PAS/AID over more expensive, possibly life-saving treatments, like chemotherapy". The survey also found that physicians generally misunderstand why patients seek PAS. 49% of physicians agreed that "Most patients who seek PAS/AID do so because of physical pain", whereas studies in Oregon found that "the three most frequently mentioned end-of-life concerns were loss of autonomy (89.5%), decreasing ability to participate in activities that made life enjoyable (89.5%), and loss of dignity (65.4%)." In addition, the survey found uncertainty about the adequacy of safeguards. While 59% agreed that "Current PAS laws provide adequate safeguards", there was greater concern with respect to specific safeguards. 60% disagreed that "Physicians who are not psychiatrists are sufficiently trained to screen for depression in patients who are seeking PAS" and 60% disagreed that "Most physicians can predict with certainty whether a patient seeking PAS/AID has 6 months or less to live". The concern about adequate safeguards is even greater among Oregon emergency physicians, among whom one study found that “Only 37% indicated that the Oregon initiative has enough safeguards to protect vulnerable persons."

Attitudes toward PAS vary by health profession as well; an extensive survey of 3733 medical physicians was sponsored by the National Council for Palliative Care, Age Concern, Help the Hospices, Macmillan Cancer Support, the Motor Neurone Disease Association, the MS Society and Sue Ryder Care showed that opposition to voluntary euthanasia and PAS was highest among Palliative Care and Care of the Elderly specialists, with more than 90% of palliative care specialists against a change in the law.

A 1997 study by Glasgow University's Institute of Law & Ethics in Medicine found pharmacists (72%) and anaesthetists (56%) to be generally in favor of legalizing PAS. Pharmacists were twice as likely as medical GPs to endorse the view that "if a patient has decided to end their own life then doctors should be allowed in law to assist". A report published in January 2017 by NPR suggests that the thoroughness of protections that allow physicians to refrain from participating in the municipalities that legalized assisted suicide within the United States presently creates a lack of access by those who would otherwise be eligible for the practice.

A poll in the United Kingdom showed that 54% of General Practitioners are either supportive or neutral towards the introduction of assisted dying laws. A similar poll on Doctors.net.uk published in the BMJ said that 55% of doctors would support it. In contrast the BMA, which represents doctors in the UK, opposes it.

An anonymous, confidential postal survey of all General Practitioners in Northern Ireland, conducted in the year 2000, found that over 70% of responding GPs were opposed to physician-assisted suicide and voluntary active euthanasia.

Legality

Current status of assisted suicide around the world:

  Physician-assisted suicide is legal

  Legalized by court ruling, but not legislated or regulated

  Physician-assisted suicide is illegal

Physician-assisted suicide is legal in some countries, under certain circumstances, including Austria, Belgium, Canada, Luxembourg, the Netherlands, New Zealand, Portugal, Spain, Switzerland and parts of the United States (California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, Washington and Washington DC) and Australia (New South Wales, Queensland, South Australia, Tasmania, Victoria and Western Australia). The Constitutional Courts of Colombia, Germany and Italy legalized assisted suicide, but their governments have not legislated or regulated the practice yet.

Australia

Main article: Euthanasia in Australia

Laws regarding assisted suicide in Australia are a matter for state and territory governments. Physician assisted suicide is currently legal in all Australian states: New South Wales, Victoria, South Australia, Western Australia, Tasmania and Queensland. It remains illegal in all Australian territories.

Under Victorian law, patients can ask medical practitioners about voluntary assisted dying, and doctors, including conscientious objectors, should refer to appropriately trained colleagues who do not conscientiously object. Health practitioners are restricted from initiating conversation or suggesting voluntary assisted dying to a patient unprompted.

Voluntary euthanasia was legal in the Northern Territory for a short time under the Rights of the Terminally Ill Act 1995, until this law was overturned by the Federal Government which also removed the ability for territories to pass legislation relating to assisted dying, however this was repealed in December 2022 with the passing of Restoring Territory Rights Act. The highly controversial 'Euthanasia Machine', the first invented voluntary assisted dying machine of its kind, created by Philip Nitschke, utilised during this period is presently held at London's Science Museum.

Austria

Current status of assisted suicide in Europe:

  Physician-assisted suicide is legal

  Legalized by court ruling, but not legislated or regulated

  Assisted suicide is not legal

In December 2020, the Austrian Constitutional Court ruled that the prohibition of assisted suicide was unconstitutional. In December 2021, the Austrian Parliament legalized assisted suicide for those who are terminally ill or have a permanent, debilitating condition.

Belgium

The Euthanasia Act legalized voluntary euthanasia in Belgium in 2002, but it did not cover physician-assisted suicide.

Canada

Main article: Assisted suicide in Canada

In Canada, physician-assisted suicide was first legalized in the Province of Quebec on 5 June 2014. It was declared nationally legal by the Supreme Court of Canada on 6 February 2015, in Carter v. Canada (Attorney General).

National legislation formalizing physician-assisted suicide passed in mid-June 2016, for patients facing an estimated death within six months. Eligibility criteria have been progressively expanded over time. As of March 2021, individuals no longer need to be terminally ill in order to qualify for assisted suicide. Legislation allowing for assisted suicide for mental illness was expected to come into force on March 17 2023, but has since been postponed until 2024.

Between 10 December 2015 and 30 June 2017, 2,149 medically assisted deaths were documented in Canada. Research published by Health Canada illustrates physician preference for physician-administered voluntary euthanasia, citing concerns about effective administration and prevention of the potential complications of self-administration by patients.

China

In China, assisted suicide is illegal under Articles 232 and 233 of the Criminal Law of the People's Republic of China. In China, suicide or neglect is considered homicide and can be punished by three to seven years in prison. In May 2011, Zhong Yichun, a farmer, was sentenced to two years imprisonment by the People's Court of Longnan County, in China's Jiangxi Province for assisting Zeng Qianxiang to die by suicide. Zeng had a mental illness and repeatedly asked Zhong to help him die by suicide. In October 2010, Zeng took excessive sleeping pills and lay in a cave. As planned, Zhong called him 15 minutes later to confirm that he was dead and buried him. However, according to the autopsy report, the cause of death was from suffocation, not an overdose. Zhong was convicted of criminal negligence. In August 2011, Zhong appealed the court sentence, but it was rejected.

In 1992, a physician was accused of murdering a patient with advanced cancer by lethal injection. He was eventually acquitted.

Colombia

In May 1997 the Colombian Constitutional Court allowed for the voluntary euthanasia of sick patients who requested to end their lives, by passing Article 326 of the 1980 Penal Code. This ruling owes its success to the efforts of a group that strongly opposed voluntary euthanasia. When one of its members brought a lawsuit to the Colombian Supreme Court against it, the court issued a 6 to 3 decision that "spelled out the rights of a terminally ill person to engage in voluntary euthanasia".

Publicized cases

In January 2022 Victor Escobar became the first person in the Andean country with a non-terminal illness to die by legally regulated euthanasia. The 60-year-old Escobar had end-stage chronic obstructive pulmonary disease.

Denmark

Assisted suicide is illegal in Denmark. Passive euthanasia, or the refusal to accept treatment, is not illegal. A survey from 2014 found that 71% of Denmark's population was in favor of legalizing voluntary euthanasia and physician-assisted suicide.

France

Assisted suicide is not legal in France. The controversy over legalising voluntary euthanasia and physician-assisted suicide is not as big as in the United States because of the country's "well developed hospice care programme". However, in 2000 the controversy over the topic was ignited with Vincent Humbert. After a car crash that left him "unable to 'walk, see, speak, smell or taste'", he used the movement of his right thumb to write a book, I Ask the Right to Die (Je vous demande le droit de mourir), in which he voiced his desire to "die legally". After his appeal was denied, his mother assisted in killing him by injecting him with an overdose of barbiturates that put him into a coma, killing him two days later. Though his mother was arrested for aiding in her son's death and later acquitted, the case did jump-start new legislation which states that when medicine serves "no other purpose than the artificial support of life" it can be "suspended or not undertaken".

Germany

Killing somebody in accordance with their demands is always illegal under the German criminal code (Paragraph 216, "Killing at the request of the victim").

Assisting suicide is generally legal and the Federal Constitutional Court has ruled that it is generally protected under the Basic Law; in 2020, it overturned a ban on the commercialization of assisted suicide. Since suicide itself is legal, assistance or encouragement is not punishable by the usual legal mechanisms dealing with complicity and incitement (German criminal law follows the idea of "accessories of complicity" which states that "the motives of a person who incites another person to commit suicide, or who assists in its commission, are irrelevant").

Travel to Switzerland

Between 1998 and 2018 around 1250 German citizens (almost three times the number of any other nationality) travelled to Dignitas in Zurich, Switzerland, for an assisted suicide, where this has been legal since 1998. Switzerland is one of the few countries that permit assisted suicide for non-resident foreigners.

Physician-assisted suicide

Physician-assisted suicide was formally legalised on 26 February 2020 when Germany's top court removed the prohibition of "professionally assisted suicide".

Iceland

Assisted suicide is illegal.

Ireland

Assisted suicide is illegal. "Both euthanasia and assisted suicide are illegal under Irish law. Depending on the circumstances, euthanasia is regarded as either manslaughter or murder and is punishable by up to life imprisonment."

Italy

On 25 September 2019, the Italian Constitutional Court ruling 242/2019 declared that article 580 of the criminal code was unconstitutional; the decriminalisation of assisted suicide in the case of those who aid people who suffer from an irreversible pathology to die, effectively legalised assisted suicide. The Italian Parliament has not yet passed a law regulating assisted suicide. On 16 June 2022, the first assisted suicide was performed.

Jersey

On 25 November 2021, the States Assembly voted to legalise assisted dying and a law legalising it will be drafted in due course. The Channel Island is the first country in the British Islands to approve the measure. The proposition, which was lodged by the Council of Ministers, proposes that a legal assisted dying service should be set up for residents over the age of 18 with a terminal illness or other incurable suffering. The service will be voluntary and methods are either physician-assisted suicide or euthanasia.

This follows a campaign and overwhelming public support. Paul Gazzard and his late husband Alain du Chemin were key actors in the campaign in favour of legalising assisted dying. A citizen's jury was established, which recommended that assisted dying be legalised in the island.

Luxembourg

After again failing to get royal assent for legalizing voluntary euthanasia and physician-assisted suicide, in December 2008 Luxembourg's parliament amended the country's constitution to take this power away from the monarch, the Grand Duke of Luxembourg. Voluntary euthanasia and physician-assisted suicide were legalized in the country in April 2009.

Netherlands

Main article: Euthanasia in the Netherlands

The Netherlands was the first country in the world to formally legalise voluntary euthanasia. Physician-assisted suicide is legal under the same conditions as voluntary euthanasia. Physician-assisted suicide became allowed under the Act of 2001 which states the specific procedures and requirements needed in order to provide such assistance. Assisted suicide in the Netherlands follows a medical model which means that only doctors of patients who are suffering "unbearably without hope" are allowed to grant a request for an assisted suicide. The Netherlands allows people over the age of 12 to pursue an assisted suicide when deemed necessary.

New Zealand

Main article: Euthanasia in New Zealand

Assisted suicide was decriminalised after a binding referendum in 2020 on New Zealand's End of Life Choice Act 2019. The legislation provided for a year-long delay before it took effect on 6 November 2021. Under Section 179 of the Crimes Act 1961, it is illegal to 'aid and abet suicide' and this will remain the case outside the framework established under the End of Life Choice Act.

Norway

Assisted suicide is illegal in Norway. It is considered murder and is punishable by up to 21 years imprisonment.

South Africa

South Africa is struggling with the debate over legalizing voluntary euthanasia and physician-assisted suicide. Owing to the underdeveloped health care system that pervades the majority of the country, Willem Landman, "a member of the South African Law Commission, at a symposium on euthanasia at the World Congress of Family Doctors" stated that many South African doctors would be willing to perform acts of voluntary euthanasia when it became legalized in the country. He feels that because of the lack of doctors in the country, "[legalizing] euthanasia in South Africa would be premature and difficult to put into practice ...".

On 30 April 2015, the High Court in Pretoria granted Advocate Robin Stransham-Ford an order that would allow a doctor to assist him in taking his own life without the threat of prosecution. On 6 December 2016, the Supreme Court of Appeal overturned the High Court ruling.

Switzerland

Main article: Euthanasia in Switzerland

Though it is illegal to assist a patient in dying in some circumstances, there are others where there is no offence committed. The relevant provision of the Swiss Criminal Code refers to "a person who, for selfish reasons, incites someone to commit suicide or who assists that person in doing so will, if the suicide was carried out or attempted, be sentenced to a term of imprisonment (Zuchthaus) of up to 5 years or a term of imprisonment (Gefängnis)."

A person brought to court on a charge could presumably avoid conviction by proving that they were "motivated by the good intentions of bringing about a requested death for the purposes of relieving "suffering" rather than for "selfish" reasons. In order to avoid conviction, the person has to prove that the deceased knew what he or she was doing, had the capacity to make the decision, and had made an "earnest" request, meaning they asked for death several times. The person helping also has to avoid actually doing the act that leads to death, lest they be convicted under Article 114: Killing on request (Tötung auf Verlangen) – A person who, for decent reasons, especially compassion, kills a person on the basis of his or her serious and insistent request, will be sentenced to a term of imprisonment (Gefängnis). For instance, it should be the suicide subject who actually presses the syringe or takes the pill, after the helper had prepared the setup. This way the country can criminalise certain controversial acts, which many of its people would oppose, while legalising a narrow range of assistive acts for some of those seeking help to end their lives.

Switzerland is one of only a handful of countries in the world which permits assisted suicide for non-resident foreigners, causing what some critics have described as suicide tourism. Between 1998 and 2018 around 1250 German citizens (almost three times the number of any other nationality) travelled to Dignitas in Zurich, Switzerland, for an assisted suicide. During the same period over 400 British citizens also opted to end their life at the same clinic.

In May 2011, Zurich held a referendum that asked voters whether (i) assisted suicide should be prohibited outright; and (ii) whether Dignitas and other assisted suicide providers should not admit overseas users. Zurich voters heavily rejected both bans, despite anti-euthanasia lobbying from two Swiss social conservative political parties, the Evangelical People's Party of Switzerland and Federal Democratic Union. The outright ban proposal was rejected by 84% of voters, while 78% voted to keep services open should overseas users require them.

In Switzerland non-physician-assisted suicide is legal, the assistance mostly being provided by volunteers, whereas in Belgium and the Netherlands, a physician must be present. In Switzerland, the doctors are primarily there to assess the patient's decision capacity and prescribe the lethal drugs. Additionally, unlike cases in the United States, a person is not required to have a terminal illness but only the capacity to make decisions. About 25% of people in Switzerland who take advantage of assisted suicide do not have a terminal illness but are simply old or "tired of life".

Publicized cases

In January 2006 British doctor Anne Turner took her own life in a Zurich clinic having developed an incurable degenerative disease. Her story was reported by the BBC and later, in 2009, made into a TV film A Short Stay in Switzerland starring Julie Walters.

In July 2009, British conductor Sir Edward Downes and his wife Joan died together at a suicide clinic outside Zürich "under circumstances of their own choosing". Sir Edward was not terminally ill, but his wife was diagnosed with rapidly developing cancer.

In March 2010, the American PBS TV program Frontline showed a documentary called The Suicide Tourist which told the story of Professor Craig Ewert, his family, and Dignitas, and his decision to die by assisted suicide using sodium pentobarbital in Switzerland after he was diagnosed and suffering with ALS (Lou Gehrig's disease).^[154]

In June 2011, the BBC televised the assisted suicide of Peter Smedley, a canning factory owner, who was suffering from motor neurone disease. The programme – Sir Terry Pratchett's Choosing To Die – told the story of Smedley's journey to the end where he used The Dignitas Clinic, a voluntary euthanasia clinic in Switzerland, to assist him in carrying out his suicide. The programme shows Smedley eating chocolates to counter the unpalatable taste of the liquid he drinks to end his life. Moments after drinking the liquid, Smedley begged for water, gasped for breath and became red, he then fell into a deep sleep where he snored heavily while holding his wife's hand. Minutes later, Smedley stopped breathing and his heart stopped beating.

Uruguay

Main article: Euthanasia in Uruguay

Assisted suicide, while criminal, does not appear to have caused any convictions, as article 37 of the Penal Code (effective 1934) states: "The judges are authorized to forego punishment of a person whose previous life has been honorable where he commits a homicide motivated by compassion, induced by repeated requests of the victim."

United Kingdom

Main article: Assisted suicide in the United Kingdom

England and Wales

Deliberately assisting a suicide is illegal. Between 2003 and 2006, Lord Joffe made four attempts to introduce bills that would have legalised physician-assisted suicide in England and Wales. All were rejected by the UK Parliament. In the meantime, the Director of Public Prosecutions has clarified the criteria under which an individual will be prosecuted in England and Wales for assisting in another person's suicide. These have not been tested by an appellate court as yet. In 2014, Lord Falconer of Thoroton tabled an Assisted Dying Bill in the House of Lords which passed its Second Reading but ran out of time before the General Election. During its passage peers voted down two amendments which were proposed by opponents of the Bill. In 2015, Labour MP Rob Marris introduced another Bill, based on the Falconer proposals, in the House of Commons. The Second Reading was the first time the House was able to vote on the issue since 1997. A Populus poll had found that 82% of the British public agreed with the proposals of Lord Falconer's Assisted Dying Bill. However, in a free vote on 11 September 2015, only 118 MPs were in favour and 330 against, thus defeating the bill.

Scotland

Unlike the other jurisdictions in the United Kingdom, suicide was not illegal in Scotland before 1961 (and still is not) thus no associated offences were created in imitation. Depending on the actual nature of any assistance given to a suicide, the offences of murder or culpable homicide might be committed or there might be no offence at all; the nearest modern prosecutions bearing comparison might be those where a culpable homicide conviction has been obtained when drug addicts have died unintentionally after being given "hands on" non-medical assistance with an injection. Modern law regarding the assistance of someone who intends to die has a lack of certainty as well as a lack of relevant case law; this has led to attempts to introduce statutes providing more certainty.

Independent MSP Margo MacDonald's "End of Life Assistance Bill" was brought before the Scottish Parliament to permit physician-assisted suicide in January 2010. The Catholic Church and the Church of Scotland, the largest denomination in Scotland, opposed the bill. The bill was rejected by a vote of 85–16 (with 2 abstentions) in December 2010.

The Assisted Suicide (Scotland) Bill was introduced on 13 November 2013 by the late Margo MacDonald MSP and was taken up by Patrick Harvie MSP on Ms MacDonald's death. The Bill entered the main committee scrutiny stage in January 2015 and reached a vote in Parliament several months later; however the bill was again rejected.

Northern Ireland

Health is a devolved matter in the United Kingdom and as such it would be for the Northern Ireland Assembly to legislate for assisted dying as it sees fit. As of 2018, there has been no such bill tabled in the Assembly.

United States

Main article: Assisted suicide in the United States

State laws regarding assisted suicide in the United States

---

  Legal

  Legal under court ruling¹

  Illegal

---

¹ In its 2009 decision Baxter v. Montana, the Montana Supreme Court ruled that assisted suicide did not violate Montana legal precedent or state statutes, even though no Montana laws specifically allowed it.

Physician-assisted dying was first legalized by the 1994 Oregon Death with Dignity Act, with effect delayed by lawsuits until 1997. The Montana Supreme Court ruled in Baxter v. Montana (2009) that it found no state law or public policy reason that would prohibit physician-assisted dying.

It was legalized by Washington (state) in 2008, Vermont in 2013, California and Washington, D.C., and Colorado in 2016, Hawaii in 2018, New Jersey in 2019, Maine in 2020, and New Mexico in 2021 It had also been briefly legal in New Mexico in 2014 and 2015 due to a court decision that was overturned.

Access to the procedure is generally restricted to people with a terminal illness and less than six months to live. Patients are generally required to be mentally healthy, to get approval from multiple doctors, and to affirm the request multiple times.

The punishment for participating in physician-assisted death varies throughout the other states. The state of Wyoming does not "recognize common law crimes and does not have a statute specifically prohibiting physician-assisted suicide". In Florida, "every person deliberately assisting another in the commission of self-murder shall be guilty of manslaughter, a felony of the second degree".