Provision of medical assistance in dying: a scoping review

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Abstract

Objectives

The purpose of this study is to map the characteristics of the existing medical literature describing the medications, settings, participants and outcomes of medical assistance in dying (MAID) in order to identify knowledge gaps and areas for future research.

Design

Scoping review.

Search strategy

We searched electronic databases (MEDLINE, EMBASE, PsychINFO, CINAHL and CENTRAL), clinical trial registries, conference abstracts and professional guidelines from jurisdictions where MAID is legal, up to February 2020. Eligible report types included technical summaries, institutional policies, practice surveys, practice guidelines and clinical studies that describe MAID provision in adults who have provided informed consent for MAID.

Results

163 articles published between 1989 and 2020 met eligibility criteria. 75 studies described details for MAID administered by intravenous medications and 50 studies provided data on oral medications. In intravenous protocols, MAID was most commonly administered using a barbiturate (34/163) or propofol (22/163) followed by a neuromuscular blocker. Oral protocols most often used barbiturates alone (37/163) or in conjunction with an opioid medication (7/163) and often recommended using a prokinetic agent prior to lethal drug ingestion. Complications included prolonged duration of the dying process, difficulty in obtaining intravenous access and difficulty in swallowing oral agents. Most commonly, the role of physicians was prescribing (83/163) and administering medications (75/163). Nurses’ roles included administering medications (17/163) and supporting the patient (16/163) or family (13/163). The role of families involved providing support to the patient (17/163) and bringing medications from the pharmacy for self-administration (4/163).

Conclusions

We identified several trends in MAID provision including common medications and doses for oral and parenteral administration, roles of healthcare professionals and families, and complications that may cause patient, family and provider distress. Future research should aim to identify the medications, dosages, and administration techniques and procedures that produce the most predictable outcomes and mitigate distress for those involved.

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Most cited references 8

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Physicians' experiences with the Oregon Death with Dignity Act.

V Lee, Molly A Delorit, John Kraemer … (2000)

Physician-assisted suicide was legalized in Oregon in October 1997. There are data on patients who have received prescriptions for lethal medications and died after taking the medications. There is little information, however, on physicians' experiences with requests for assistance with suicide. Between February and August 1999, we mailed a questionnaire to physicians who were eligible to prescribe lethal medications under the Oregon Death with Dignity Act. Of 4053 eligible physicians, 2649 (65 percent) returned the survey. Of the respondents, 144 (5 percent) had received a total of 221 requests for prescriptions for lethal medications since October 1997. We received information on the outcome in 165 patients (complete information for 143 patients and partial for on an additional 22). The mean age of the patients was 68 years; 76 percent had an estimated life expectancy of less than six months. Thirty-five percent requested a prescription from another physician. Twenty-nine patients (18 percent) received prescriptions, and 17 (10 percent) died from administering the prescribed medication. Twenty percent of the patients had symptoms of depression; none of these patients received a prescription for a lethal medication. In the case of 68 patients, including 11 who received prescriptions and 8 who died by taking the prescribed medication, the physician implemented at least one substantive palliative intervention, such as control of pain or other symptoms, referral to a hospice program, a consultation, or a trial of antidepressant medication. Forty-six percent of the patients for whom substantive interventions were made changed their minds about assisted suicide, as compared with 15 percent of those for whom no substantive interventions were made (P<0.001). Our data indicate that in Oregon, physicians grant about 1 in 6 requests for a prescription for a lethal medication and that 1 in 10 requests actually result in suicide. Substantive palliative interventions lead some--but not all--patients to change their minds about assisted suicide.

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Legalized physician-assisted suicide in Oregon--the first year's experience.

Brian K Higginson, Joseph D Fleming, Pamela Chin … (1999)

On October 27, 1997, Oregon legalized physician-assisted suicide. We collected data on all terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. The data were obtained from physicians' reports, death certificates, and interviews with physicians. We compared persons who took lethal medications prescribed under the act with those who died from similar illnesses but did not receive prescriptions for lethal medications. Information on 23 persons who received prescriptions for lethal medications was reported to the Oregon Health Division; 15 died after taking the lethal medications, 6 died from underlying illnesses, and 2 were alive as of January 1, 1999. The median age of the 15 patients who died after taking lethal medications was 69 years; 8 were male, and all 15 were white. Thirteen of the 15 patients had cancer. The case patients and controls were similar with regard to sex, race, urban or rural residence, level of education, health insurance coverage, and hospice enrollment. No case patients or controls expressed concern about the financial impact of their illness. One case patient and 15 controls expressed concern about inadequate control of pain (P=0.10). The case patients were more likely than the controls to have never married (P=0.04) and were more likely to be concerned about loss of autonomy due to illness (P=0.01) and loss of control of bodily functions (P=0.02). At death, 21 percent of the case patients and 84 percent of the controls were completely disabled (P<0.001). During the first year of legalized physician-assisted suicide in Oregon, the decision to request and use a prescription for lethal medication was associated with concern about loss of autonomy or control of bodily functions, not with fear of intractable pain or concern about financial loss. In addition, we found that the choice of physician-assisted suicide was not associated with level of education or health insurance coverage.

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Clinical problems with the performance of euthanasia and physician-assisted suicide in The Netherlands.

D Willems, G Horst, Janet Bijl … (2000)

The characteristics and frequency of clinical problems with the performance of euthanasia and physician-assisted suicide are uncertain. We analyzed data from two studies of euthanasia and physician-assisted suicide in The Netherlands (one conducted in 1990 and 1991 and the other in 1995 and 1996), with a total of 649 cases. We categorized clinical problems as technical problems, such as difficulty inserting an intravenous line; complications, such as myoclonus or vomiting; or problems with completion, such as a longer-than-expected interval between the administration of medications and death. In 114 cases, the physician's intention was to provide assistance with suicide, and in 535, the intention was to perform euthanasia. Problems of any type were more frequent in cases of assisted suicide than in cases of euthanasia. Complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively. The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent), which thus became cases of euthanasia. The reasons for this decision included problems with completion (in 12 cases) and the inability of the patient to take all the medications (in 5). There may be clinical problems with the performance of euthanasia and physician-assisted suicide. In The Netherlands, physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient's inability to take the medication or because of problems with the completion of physician-assisted suicide.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2020

Publication date (Electronic): 8 July 2020

Volume: 10

Issue: 7

Electronic Location Identifier: e036054

Affiliations

[1 ]departmentDepartment of Emergency Medicine , Faculty of Medicine, University of Ottawa , Ottawa, Ontario, Canada

[2 ]departmentDepartment of Medicine , McMaster University , Hamilton, Ontario, Canada

[3 ]departmentDivision of Critical Care Medicine , Western University , London, Ontario, Canada

[4 ]Hamilton Health Sciences , Hamilton, Ontario, Canada

[5 ]departmentDepartment of Clinical and Organizational Ethics , The Ottawa Hospital , Ottawa, Ontario, Canada

[6 ]departmentDivision of Emergency Medicine, Department of Medicine , Hamilton Health Sciences , Hamilton, Ontario, Canada

[7 ]departmentDepartment for Primary and Community Care , Radboudumc , Nijmegen, The Netherlands

[8 ]departmentDepartment of Health Research Methods, Evidence, and Impact , McMaster University , Hamilton, Ontario, Canada

Author notes

[Correspondence to ] Dr Max Zworth; max.zworth@ 123456medportal.ca

Author information

Max Zworth http://orcid.org/0000-0002-9120-998X

Simon Oczkowski http://orcid.org/0000-0002-2874-8948

Article

Publisher ID: bmjopen-2019-036054

DOI: 10.1136/bmjopen-2019-036054

PMC ID: 7348461

PubMed ID: 32641328

SO-VID: ba383973-6ec6-41ab-ae07-da0a902d5893

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 11 December 2019

Date revision received : 25 May 2020

Date accepted : 29 May 2020

Funding

Funded by: Hamilton Academic Health Sciences Organization’s Innovation Fund;

Funded by: McMaster Medical Student Research Excellence Scholarship (MAC RES);

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ScienceOpen disciplines: Medicine

Keywords: palliative care,adult intensive & critical care,protocols & guidelines,medical ethics

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ScienceOpen disciplines: Medicine

Keywords: palliative care, adult intensive & critical care, protocols & guidelines, medical ethics

Provision of medical assistance in dying: a scoping review

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Abstract

Objectives

Design

Search strategy

Results

Conclusions

Related collections

International Journal of Medicine and Medical Research

Most cited references 8

Physicians' experiences with the Oregon Death with Dignity Act.

Legalized physician-assisted suicide in Oregon--the first year's experience.

Clinical problems with the performance of euthanasia and physician-assisted suicide in The Netherlands.

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