Motivations of physicians and nurses to practice voluntary euthanasia: a systematic review

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Abstract

Background

While a number of reviews have explored the attitude of health professionals toward euthanasia, none of them documented their motivations to practice euthanasia. The objective of the present systematic review was to identify physicians’ and nurses’ motives for having the intention or for performing an act of voluntary euthanasia and compare findings from countries where the practice is legalized to those where it is not.

Methods

The following databases were investigated: MEDLINE/PubMed (1950+), PsycINFO (1806+), CINAHL (1982+), EMBASE (1974+) and FRANCIS (1984+). Proquest Dissertations and Theses (1861+) was also investigated for gray literature. Additional studies were included by checking the references of the articles included in the systematic review as well as by looking at our personal collection of articles on euthanasia.

Results

This paper reviews a total of 27 empirical quantitative studies out of the 1 703 articles identified at the beginning. Five studies were in countries where euthanasia is legal and 22 in countries where it is not. Seventeen studies were targeting physicians, 9 targeted nurses and 1 both health professionals. Six studies identified the motivations underlying the intention to practice euthanasia, 16 the behavior itself and 5 both intention and behavior. The category of variables most consistently associated with euthanasia is psychological variables. All categories collapsed, the four variables most frequently associated with euthanasia are past behavior, medical specialty, whether the patient is depressed and the patient’s life expectancy.

Conclusions

The present review suggests that physicians and nurses are motivated to practice voluntary euthanasia especially when they are familiar with the act of euthanasia, when the patient does not have depressive symptoms and has a short life expectancy and their motivation varies according to their medical specialty. Additional studies among nurses and in countries where euthanasia is legal are needed.

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Most cited references 39

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Loss to follow-up in cohort studies: how much is too much?

Vicki Kristman, Michael Manno, Pierre Côté (2003)

Loss to follow-up is problematic in most cohort studies and often leads to bias. Although guidelines suggest acceptable follow-up rates, the authors are unaware of studies that test the validity of these recommendations. The objective of this study was to determine whether the recommended follow-up thresholds of 60-80% are associated with biased effects in cohort studies. A simulation study was conducted using 1000 computer replications of a cohort of 500 observations. The logistic regression model included a binary exposure and three confounders. Varied correlation structures of the data represented various levels of confounding. Differing levels of loss to follow-up were generated through three mechanisms: missing completely at random (MCAR), missing at random (MAR) and missing not at random (MNAR). The authors found no important bias with levels of loss that varied from 5 to 60% when loss to follow-up was related to MCAR or MAR mechanisms. However, when observations were lost to follow-up based on a MNAR mechanism, the authors found seriously biased estimates of the odds ratios with low levels of loss to follow-up. Loss to follow-up in cohort studies rarely occurs randomly. Therefore, when planning a cohort study, one should assume that loss to follow-up is MNAR and attempt to achieve the maximum follow-up rate possible.

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What you see may not be what you get: a brief, nontechnical introduction to overfitting in regression-type models.

Michael A. Babyak (2015)

Statistical models, such as linear or logistic regression or survival analysis, are frequently used as a means to answer scientific questions in psychosomatic research. Many who use these techniques, however, apparently fail to appreciate fully the problem of overfitting, ie, capitalizing on the idiosyncrasies of the sample at hand. Overfitted models will fail to replicate in future samples, thus creating considerable uncertainty about the scientific merit of the finding. The present article is a nontechnical discussion of the concept of overfitting and is intended to be accessible to readers with varying levels of statistical expertise. The notion of overfitting is presented in terms of asking too much from the available data. Given a certain number of observations in a data set, there is an upper limit to the complexity of the model that can be derived with any acceptable degree of uncertainty. Complexity arises as a function of the number of degrees of freedom expended (the number of predictors including complex terms such as interactions and nonlinear terms) against the same data set during any stage of the data analysis. Theoretical and empirical evidence--with a special focus on the results of computer simulation studies--is presented to demonstrate the practical consequences of overfitting with respect to scientific inference. Three common practices--automated variable selection, pretesting of candidate predictors, and dichotomization of continuous variables--are shown to pose a considerable risk for spurious findings in models. The dilemma between overfitting and exploring candidate confounders is also discussed. Alternative means of guarding against overfitting are discussed, including variable aggregation and the fixing of coefficients a priori. Techniques that account and correct for complexity, including shrinkage and penalization, also are introduced.

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Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey.

Bregje Onwuteaka-Philipsen, Arianne Brinkman-Stoppelenburg, Corine Penning … (2012)

In 2002, the euthanasia act came into effect in the Netherlands, which was followed by a slight decrease in the euthanasia frequency. We assessed frequency and characteristics of euthanasia, physician-assisted suicide, and other end-of-life practices in 2010, and assessed trends since 1990. In 1990, 1995, 2001, 2005, and 2010 we did nationwide studies of a stratified sample from the death registry of Statistics Netherlands, to which all deaths and causes were reported. We mailed questionnaires to physicians attending these deaths (2010: n=8496 deaths). All cases were weighted to adjust for the stratification procedure and for differences in response rates in relation to the age, sex, marital status, region of residence, and cause and place of death. In 2010, of all deaths in the Netherlands, 2·8% (95% CI 2·5-3·2; 475 of 6861) were the result of euthanasia. This rate is higher than the 1·7% (1·5-1·8; 294 of 9965) in 2005, but comparable with those in 2001 and 1995. Distribution of sex, age, and diagnosis was stable between 1990 and 2010. In 2010, 77% (3136 of 4050) of all cases of euthanasia or physician-assisted suicide were reported to a review committee (80% [1933 of 2425] in 2005). Ending of life without an explicit patient request in 2010 occurred less often (0·2%; 95% CI 0·1-0·3; 13 of 6861) than in 2005, 2001, 1995, and 1990 (0·8%; 0·6-1·1; 45 of 5197). Continuous deep sedation until death occurred more frequently in 2010 (12·3% [11·6-13·1; 789 of 6861]) than in 2005 (8·2% [7·8-8·6; 521 of 9965]). Of all deaths in 2010, 0·4% (0·3-0·6; 18 of 6861) were the result of the patient's decision to stop eating and drinking to end life; in half of these cases the patient had made a euthanasia request that was not granted. Our study provides insight in consequences of regulating euthanasia and physician-assisted suicide within the broader context of end-of-life practices. In the Netherlands the euthanasia law resulted in a relatively transparent practice. Although translating these results to other countries is not straightforward, they can inform the debate on legalisation of assisted dying in other countries. The Netherlands Organization for Research and Development (ZonMw). Copyright © 2012 Elsevier Ltd. All rights reserved.

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Author and article information

Contributors

Lydi-Anne Vézina-Im

Mireille Lavoie

Pawel Krol

Marianne Olivier-D’Avignon

Journal

Journal ID (nlm-ta): BMC Palliat Care

Journal ID (iso-abbrev): BMC Palliat Care

Title: BMC Palliative Care

Publisher: BioMed Central

ISSN (Electronic): 1472-684X

Publication date Collection: 2014

Publication date (Electronic): 10 April 2014

Volume: 13

Page: 20

Affiliations

[1 ]Faculty of Nursing, Laval University, Québec, Canada

[2 ]Équipe de Recherche Michel-Sarrazin en Oncologie psychosociale et Soins palliatifs (ERMOS), Centre de recherche du CHU de Québec - Hôtel-Dieu de Québec, Québec, Canada

[3 ]Department of Social Sciences, Université du Québec à Chicoutimi (UQAC), Québec, Canada

Article

Publisher ID: 1472-684X-13-20

DOI: 10.1186/1472-684X-13-20

PMC ID: 4021095

PubMed ID: 24716567

SO-VID: 77e4ddc5-1055-4274-8c56-432c8044e494

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Motivations of physicians and nurses to practice voluntary euthanasia: a systematic review

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Most cited references 39

Loss to follow-up in cohort studies: how much is too much?

What you see may not be what you get: a brief, nontechnical introduction to overfitting in regression-type models.

Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey.

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