Monday and non-Monday concentrations of lifestyle-related blood components in the Oslo Diet and Exercise Study

CONTEXT: Despite intense debates about legalization, there are few data examining the details of actual euthanasia and physician-assisted suicide (PAS) cases in the United States. OBJECTIVE: To determine whether the practices of euthanasia and PAS are consistent with proposed safeguards and the effect on physicians of having performed euthanasia or PAS. DESIGN: Structured in-depth telephone interviews. SETTING AND PARTICIPANTS: Randomly selected oncologists in the United States. OUTCOME MEASURES: Adherence to primary and secondary safeguards for the practice of euthanasia and PAS; regret, comfort, and fear of prosecution from performing euthanasia or PAS. RESULTS: A total of 355 oncologists (72.6% response rate) were interviewed on euthanasia and PAS. On 2 screening questions, 56 oncologists (15.8%) reported participating in euthanasia or PAS; 53 oncologists (94.6% response rate) participated in in-depth interviews. Thirty-eight of 53 oncologists described clearly defined cases of euthanasia or PAS. Twenty-three patients (60.5%) both initiated and repeated their request for euthanasia or PAS, but 6 patients (15.8%) did not participate in the decision for euthanasia or PAS. Thirty-seven patients (97.4%) were experiencing unremitting pain or such poor physical functioning they could not perform self-care. Physicians sought consultation in 15 cases (39.5%). Overall, oncologists adhered to all 3 main safeguards in 13 cases (34.2%): (1) having the patient initiate and repeat the request for euthanasia or PAS, (2) ensuring the patient was experiencing extreme physical pain or suffering, and (3) consulting with a colleague. Those who adhered to the safeguards had known their patients longer and tended to be more religious. In 28 cases (73.7%), the family supported the decision. In all cases of pain, patients were receiving narcotic analgesia. Fifteen patients (39.5%) were enrolled in a hospice. While 19 oncologists (52.6%) received comfort from having helped a patient with euthanasia or PAS, 9 (23.7%) regretted having performed euthanasia or PAS, and 15 (39.5%) feared prosecution. CONCLUSIONS: Intractable pain or poor physical functioning seem to be nearly absolute requirements for physicians to perform euthanasia or PAS. Only one third of cases are performed consistently with proposed safeguards. For some patients, end-of-life care that includes opioid analgesia and hospice care does not obviate their desire for euthanasia or PAS. While the majority of physicians seem comforted by their actions, some experience adverse consequences from having performed euthanasia or PAS.     

Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists, and the public

BACKGROUND: Euthanasia and physician-assisted suicide are pressing public issues. We aimed to collect empirical data on these controversial interventions, particularly on the attitudes and experiences of oncology patients. METHODS: We interviewed, by telephone with vignette-style questions, 155 oncology patients, 355 oncologists, and 193 members of the public to assess their attitudes and experiences in relation to euthanasia and physician-assisted suicide. FINDINGS: About two thirds of oncology patients and the public found euthanasia and physician-assisted suicide acceptable for patients with unremitting pain. Oncology patients and the public found euthanasia and physician-assisted suicide least acceptable in vignettes involving "burden on the family" and "life viewed as meaningless". In no vignette--even for patients with unremitting pain--did a majority of oncologists find euthanasia or physician-assisted suicide ethically acceptable. Patients actually experiencing pain were more likely to find euthanasia or physician-assisted suicide unacceptable. More than a quarter of oncology patients had seriously thought about euthanasia or physician-assisted suicide and nearly 12 percent had seriously discussed these interventions with physicians or others. Patients with depression and psychological distress were significantly more likely to have seriously discussed euthanasia, hoarded drugs, or read Final Exit. More than half of oncologists had received requests for euthanasia or physician-assisted suicide. Nearly one in seven oncologists had carried out euthanasia or physician-assisted suicide. INTERPRETATION: Euthanasia and physician-assisted suicide are important issues in the care of terminally ill patients and while oncology patients experiencing pain are unlikely to desire these interventions patients with depression are more likely to request assistance in committing suicide. Patients who request such an intervention should be evaluated and, where appropriate, treated for depression before euthanasia can be discussed seriously.     

Attitude towards physician-assisted suicide among German doctors. A representative survey of the medical district association of Würzburg

BACKGROUND AND OBJECTIVE: The widespread legalization of "physician assisted suicide" (PAS) in The Netherlands and comparable tendencies in other European countries have given rise to discussions of this topic in Germany. This questionnaire was undertaken because of the dearth of previous informative studies in Germany. SUBJECTS AND METHODS: Among all registered practicing doctors in the medical district of Würzburg (n = 1821) a randomly selected group of 150 (males and females) was asked to participate in a personal interview-enquiry about active and passive euthanasia. 93 (62%, 32% women, 61% men) agreed: 44.1% were doctors working in a hospital, 45.2% worked in their own practice, the others worked elsewhere or (3) were retired. All specialties and medical activities were represented. About 40% were general practitioners or worked in internal medicine. RESULTS: 81.7% of the group were against active PAS. All rejected it for non-moribund patients. CONCLUSIONS: The results of this study differ from similar enquiries in other countries in demonstrating a relatively strong rejection of active assistance in patient-suicide. Those German specialists who would most likely be confronted with this problem (e.g. neurologists, intensivists, anaesthetists, oncologists) tended towards a greater readiness to agree to physician-assisted suicide. A dialogue between doctors in different specialties is an urgent requirement and should be intensively pursued.     

Euthanasia among US critical care nurses. Practices, attitudes, and social and professional correlates

OBJECTIVES: The authors sought to identify associations between critical care nurses' self-reported participation in euthanasia, their social and professional characteristics, and their attitudes toward end-of-life care. METHODS: Data were collected through an anonymous mail survey of 1,560 US critical care nurses, of whom 1,139 (73%) responded. Nurses were asked to report whether they had received requests to engage in euthanasia and whether they had engaged in euthanasia. In addition, nurses were asked to respond to items assessing their attitudes toward end-of-life care. RESULTS: Of 852 nurses who identified themselves as practicing exclusively in adult intensive care units, 164 (19%) reported that they had engaged in euthanasia, 650 (76%) reported that they had not engaged in euthanasia, and 38 (4%) could not be classified. Only 30% of respondents believed that euthanasia is unethical. Logistic regression indicated that older nurses, more religious nurses, nurses practicing in cardiac care units, and nurses with less favorable attitudes toward euthanasia were significantly less likely to report having engaged in euthanasia, although the effects of age and religious beliefs appear to have been mediated by attitudes. CONCLUSIONS: These results help explain why some US critical care nurses engaged in euthanasia despite legal and professional prohibitions against it. Because critical care nurses may have a special understanding of the needs of critically ill patients, these results may indicate that current guidelines for end-of-life care are inadequate.     

Assisted suicide, depression, and the right to die.

The debate surrounding the legalization of assisted suicide continues despite a limited body of empirical research. Relatively few studies have addressed interest in assisted suicide or the desire for hastened death (rather than approval of legalization) among medically ill patients, and this literature is plagued by methodological limitations. In general, this research has demonstrated a significant association between depression and desire for death; however, the magnitude of this association is unclear. Nevertheless, psychological and social factors have typically appeared more influential in determining patients' desire for death than physical symptoms such as pain. The impact of these findings on future legislative efforts to legalize assisted suicide is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Willingness to perform euthanasia. A survey of physician attitudes

BACKGROUND: In the United States, few studies have examined important variables in physician attitudes toward the practice of euthanasia, such as the patient's underlying disease, mental capacity, and age, and the physician's specialty and religion. We administered a case-based survey to analyze the impact of such specific variables on physician attitudes toward the practice. METHODS: A four-section survey solicited (1) physician responses to three hypothetical cases in which patients requested euthanasia; (2) physicians' general opinions about euthanasia and how its legalization might affect them personally and professionally; and (3) demographic information. Analysis focused on physicians' characteristics as they related to their responses to the various aspects of euthanasia elicited in the survey. Univariate and multivariate analyses, using logistic regression, were performed. RESULTS: Completed and analyzable surveys were returned by 740 physicians. We found that physicians felt more comfortable with euthanasia requests from nondecisional, nonterminal patients who had left advance directives than they did with requests from decisional patients suffering from grave illnesses or injuries, or from decisional patients who had early signs of a progressive but nonlethal neurologic disease. We also found that physicians' specialties and religions correlated with their responses to the hypothetical cases and with their generalized attitudes toward euthanasia. CONCLUSIONS: Given the disparity in responding physicians' attitudes toward euthanasia, along with the fact that values based on religious affiliation or profession may underlie many physicians' opposition to the practice, we conclude that if euthanasia is to be legalized, safeguards protective of patients and physicians must be incorporated.     

Death anxiety and voluntary passive euthanasia: Influences of proximity to death and experiences with death in important other persons.

86 young and 62 elderly non-life-threatened and 63 elderly life-threatened persons (mean ages 19.5, 71.0, and 74.8 yrs, respectively) were given a standardized interview that included the Death Anxiety Scale (DAS). Age, but not health, was related to death anxiety. A significant Proximity to Death by Experience with Death in Important Others interaction occurred for both death anxiety and attitude toward voluntary passive euthanasia when the experience factor involved participants' most meaningful experiences. Principal-components analysis identified 5 sources of death anxiety (accounting for 56.7% of DAS variance): Fear of Personal Death, Concerns about Suffering and Lingering Death, Subjective Proximity to Death, Death-Related Fears, and Disturbing Death Thoughts. Significant relationships were observed between each of these and the experimental factors. A significant correlation between death anxiety and attitude toward voluntary passive euthanasia was noted among elderly persons. Results are consistent with an idiographic orientations toward death perspective. (19 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Bioethics for clinicians: 11. Euthanasia and assisted suicide

Euthanasia and assisted suicide involve taking deliberate action to end or assist in ending the life of another person on compassionate grounds. There is considerable disagreement about the acceptability of these acts and about whether they are ethically distinct from decisions to forgo life-sustaining treatment. Euthanasia and assisted suicide are punishable offences under Canadian criminal law, despite increasing public pressure for a more permissive policy. Some Canadian physicians would be willing to practise euthanasia and assisted suicide if these acts were legal. In practice, physicians must differentiate between respecting competent decisions to forgo treatment, providing appropriate palliative care, and acceeding to a request for euthanasia or assisted suicide. Physicians who believe that euthanasia and assisted suicide should be legally accepted in Canada should pursue their convictions only through legal and democratic means.     

When is a request for assisted suicide legitimate? Factors influencing public attitudes toward euthanasia.

A mail survey of 810 Vancouver area residents investigated how the public's acceptance of a request for euthanasia was influenced by the method of death (e.g., lethal injection vs withdrawal of life-support) and by the identity of the patient featured in a vignette (e.g., stranger vs oneself). The study also identified considerations people found most important in deciding whether a patient's request for euthanasia was legitimate (e.g., patient's pain, chance for recovery). Life-support withdrawal was found significantly more acceptable (90% support) than a lethal injection (79% support), yet the identity of the person involved did not affect the acceptability of euthanasia. However, a factor analysis suggested that the decisions about oneself may be more complex and more closely scrutinized than decisions about others. The considerations rated most important by participants paralleled legal guidelines from the Netherlands and Oregon. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of nurses in euthanasia: a Dutch study

What role do nurses play in euthanasia? How do they experience this role and what should be their ideal role? These are the questions of a study undertaken to gain insight into the role of nurses in euthanasia. Answers to these questions were derived from 20 semistructured in-depth interviews with nurses employed in a Dutch hospital. To make clear the role of nurses in euthanasia, the issue was split up into four phases: observation of a request for euthanasia; decision making; carrying out of the request; and aftercare. This article is a brief report on the most important results regarding these four phases. Special attention will be paid to nurses who have conscientious objections. To evaluate the study results, an unambiguous interpretation of the concept of 'euthanasia' is of most importance. For that reason, Dutch laws and other regulations concerning euthanasia will be explained.     

Beneficent voluntary active euthanasia: a challenge to professionals caring for terminally ill patients

Euthanasia has once again become headline news in the UK, with the announcement by Dr Michael Irwin, a former medical director of the United Nations, that he has helped at least 50 people to die, including two between February and July 1997. He has been quoted as saying that his 'conscience is clear' and that the time has come to confront the issue of euthanasia. For the purposes of this article, the term 'beneficient voluntary active euthanasia' (BVAE) will be used: beneficient from the prima facie principle of beneficience, to do good, and voluntary to indicate that this must be carried out at the request of a competent client. This implies adherence to another prima facie principle, that of respect for autonomy. Active implies that something is done or given with the intention of hastening death. The word euthanasia itself simply means 'good death'. This article examines the moral positions of two nurses and one junior doctor towards the subject of BVAE and an attempt is made to represent the main conflicting moral positions. The central arguments against BVAE and counterarguments are presented. The conclusion reached is that consenting adults should not be prevented from availing themselves of BVAE if another consenting adult (a medical doctor) is available and capable of carrying out their wishes. This being the case, it is suggested that BVAE should be available as an option in hospices and in the community. The aims of this article are: to generate debate among professionals; to present a three-way discussion that might be useful as a focus for educational purposes, particularly at undergraduate level; to challenge professionals to confront the issue of euthanasia; and to plead the case of those who request assistance in exercising autonomy by gaining control over their own deaths.     

Deliberation between physician and patient concerning active euthanasia at the patient's home

Three patients, one man aged 68 and two aged 67, with terminal incurable cancer, requested euthanasia. It was performed in two, the third patient eventually died without having repeated his request. There are three phases in euthanasia: orientation (the patient asks the physician whether he would be willing to assist should the need arise), organisation (the physician ensures that the necessary prerequisites are fulfilled, i.e. the patient's request must be voluntary, mature and longlasting, his suffering must be longlasting, unbearable and incurable, and another physician must have been consulted and must have prepared a written report), and the phase entered after the definitive decision to perform euthanasia has been taken. The physician should not be reluctant to bring up the subject at an early stage, as it may set the patient's mind at rest to have expressed a wish concerning suffering and the end of life.     

Gefarnate increases PAS positive cell density in rabbit conjunctiva

AIMS: The effects of three drugs for the treatment of gastritis and gastric ulcer--gefarnate, ecabet sodium, and troxipide--on periodic acid Schiff (PAS) positive cell density in rabbit conjunctiva in vivo were investigated. METHODS: Eye drops containing gefarnate (0.1%, 1%), ecabet sodium (0.1%, 1%), or troxipide (0.1%, 1%) were instilled in both eyes of rabbits, six times a day for 7 days. On the eighth day, filter paper was gently pressed on the bulbar and palpebral conjunctiva, and impression cytology was performed with PAS staining. Three points in each specimen were selected randomly, and PAS stained cells were counted. RESULTS: The instillation of gefarnate increased PAS positive cell density significantly at the concentration of 1% (p < 0.05). In contrast, instillation of ecabet sodium or troxipide failed to change PAS positive cell density. CONCLUSIONS: These results demonstrated that gefarnate stimulates PAS positive cell density in rabbit conjunctiva.     

Differences in the attitudes of couples whose children were conceived through artificial insemination by donor in 1980 and in 1996

OBJECTIVE: To compare the attitudes of couples whose children were conceived through artificial insemination by donor (AID) in 1980 and in 1996. DESIGN: Replication study. SETTING: Infertility clinic of the Utrecht university hospital. PATIENT(S): Couples who conceived a child through AID in 1980 (n = 134) or in 1996 (n = 110). INTERVENTION(S): Anonymous questionnaires. MAIN OUTCOME MEASURE(S): Answers to questionnaires. RESULT(S): Couples who conceive a child through AID still strongly prefer (84%) absolute anonymity of the donor. In both 1980 and 1996, most couples (approximately 80%) decided not to inform their child about the nature of his or her conception. In 1996, couples who considered informing their child hesitated significantly less and showed significantly more openness toward others. In addition, more couples wanted unidentifiable data about the donor and considered it more important to use the same donor for a subsequent child. CONCLUSION(S): Between 1980 and 1996, the number of couples who conceived a child through AID and adhered to absolute anonymity of the donor and secrecy toward the child remained the same, whereas their openness toward others and desire for unidentifiable data about the donor increased.     

Resisting tempting foods and smoking behavior: Implications from a self-control theory perspective.

Objective: Individuals may desire to diet or restrain from eating certain foods while attempting to quit smoking out of concern for weight gain. However, previous research and clinical tobacco treatment guidelines suggest that concurrent dieting may undermine attempts to quit smoking. The current study applied the self-control strength model, which posits that self-regulation relies on a limited strength that is consumed with use, to test whether resisting tempting sweets would lead to a greater likelihood of subsequent smoking. Design: Participants were 101 cigarette smokers randomly assigned to resist eating either from a tempting plate of sweets or from a plate of less tempting vegetables. All participants were then given a 10-min recess. Main Outcome Measures: Whether participants smoked during the break, measured with a breath carbon monoxide sample, served as the primary dependent variable. Results: As predicted, participants who resisted sweets were more likely to smoke during the break (53.2%) than those who resisted vegetables (34.0%), χ2(1, N = 101) = 3.65 p     

Zinc dependent activation of cAMP-specific phosphodiesterase (PDE4A)

OBJECTIVES: This study was undertaken to determine whether the presence of calcium in the mitral valve commissures, as demonstrated echocardiographically, could predict outcome and to compare this with an established echocardiographic scoring system. BACKGROUND: Percutaneous mitral balloon valvotomy is an effective form of treatment for mitral valve stenosis. It is important to identify patients who would benefit from this procedure. Commissural splitting is the dominant mechanism by which mitral valve stenosis is relieved by this technique, and thus commissural morphology may predict outcome. METHODS: One hundred forty-nine consecutive patients who underwent percutaneous mitral balloon valvotomy at the Mayo Clinic were evaluated retrospectively. The morphology of the mitral valve apparatus on the baseline echocardiograms was scored in blinded manner using a semiquantitative grading system of leaflet thickening, mobility, calcification and subvalvular thickening (Abascal score). Additionally, each of the medial and lateral commissures was graded for the presence or absence of calcification. End points were death, New York Heart Association functional class, repeat percutaneous mitral balloon valvotomy and mitral valve replacement at follow-up. RESULTS: The mean follow-up period was 1.8 years (maximum 7.9 years). Univariate predictors of death and all events combined included age, the use of a double-balloon technique, the presence of calcium in a commissure and the Abascal score, as continuous variables. Patients with an Abascal score < or = 8 showed a trend toward improved survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (78 +/- 6% vs. 67 +/- 8%, p = 0.07) and free of all events combined (75 +/- 6% vs. 64 +/- 8%, p = 0.07) versus those patients with a score > 8. However, survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (86 +/- 4% vs. 40 +/- 4%) and free of all events combined (82 +/- 5% vs. 38 +/- 10%) at follow-up was significantly different between patients without commissural calcium and those with commissural calcium (p < 0.001). In a Cox regression model with Abascal score and commissural calcium and their interaction, calcification emerged as the only significant variable (p < 0.01). CONCLUSIONS: The presence of commissural calcium is a strong predictor of outcome after percutaneous mitral balloon valvotomy. Patients with evidence of calcium in a commissure have a lower survival rate and a higher incidence of mitral valve replacement and all end points combined. Thus, the simple presence or absence of commissural calcification assessed by two-dimensional echocardiography can be used to predict outcome.