INTRODUCTION — In recent years, much of the developed world has seen the emergence of end-of-life debates and increasing pressures for legalization of physician-assisted dying (PAD). Many physicians, particularly those in the fields of oncology and palliative care, will be faced with a request for such assistance sometime in their professional lifetimes. As of May 2021, approximately 20 percent of the United States population lives in a jurisdiction where such a practice is legal. PAD is also legal in many other jurisdictions around the world. However, patients make these requests to physicians and other clinicians even where PAD is not legal. No matter where clinicians stand ethically and morally on the permissibility of this practice, and regardless of whether these practices are legally permitted in their jurisdiction, clinicians must carefully consider how they will respond to these requests.
This topic focuses on the definitional and descriptive aspects of physician-assisted death as well as the clinical aspects of evaluating and responding to such requests. Attention is also given to ethical, social, and legal aspects of these practices as well as the continuing challenges for the physician.
Other legal and ethical issues in palliative care, including palliative sedation, are presented elsewhere. (See "Ethical issues in palliative care" and "Legal aspects in palliative and end-of-life care in the United States" and "Palliative sedation".)
●Physician-assisted dying (PAD) – This is the practice where a physician provides a terminally ill patient, at their explicit request, with a prescription for a lethal medication that they can take on their own. Other terms used to describe this practice, including “physician-assisted suicide” (a negatively valenced term favored by opponents) and ”death with dignity” (a positively valenced term favored by proponents) [1-4], are outlined in the table (table 1). The legal terminology varies by location. As of May 2021, all statutes in the United States incorporate the substance of Oregon’s original assertion that actions taken in accord with the statute shall not for any purpose constitute suicide, assisted suicide, mercy killing, or homicide under the law (table 2).
●Voluntary active euthanasia – Voluntary active euthanasia (VAE), or simply “euthanasia,” are terms used to identify the practice whereby the clinician administers a lethal medication at the patient’s request, usually by intravenous push injection.
The term “euthanasia” varies sharply in its negative or positive connotations in different regions. In the Netherlands, “euthanasia” has generally positive connotations, associated with the Greek roots “eu” and “thanatos,” or “good death.” By contrast, the broader term “euthanasia” is avoided in Germany, where it is often associated with Nazi extermination policies, suggesting a politically motivated death that is against the victim’s wishes or interests (involuntary euthanasia). The term “passive euthanasia,” referring to death brought about by “allowing to die” or by withholding or withdrawing life-sustaining treatment, is no longer in common use in the United States or elsewhere. Nonvoluntary euthanasia (as distinct from involuntary euthanasia) is known in the Netherlands as LAWER, “life-ending acts without explicit (current) request,” typically performed in a no-longer-competent patient who is close to death. Involuntary euthanasia is illegal everywhere. In this topic, we use VAE because of its common usage in the literature and because there is no internationally recognized neutral term available.
●Medical aid in dying – Medical aid in dying, or medical assistance in dying (MAID), a term originating in Canada, is used to refer to both PAD and VAE, replacing either or both . Similarly, Voluntary Assisted Dying (VAD) refers primarily to PAD but also VAE in Australia. In general usage, MAID supplants more complex expressions, such as “patient-administered physician-hastened death” (for PAD) and “physician-administered physician-hastened death” (for VAE), terms that had been intended to ensure there is no misunderstanding and to clearly distinguish these practices from “palliative care.” In the United States, MAID typically refers to only PAD (patient-administered, physician-hastened death). Given the variability in usage, in this topic, we use the acronym MAID where it is not necessary to distinguish between PAD and VAE.
REQUIREMENTS OF ASSISTED DYING PRACTICES
Physician-assisted dying — Physician-assisted dying (PAD) is a practice in which the physician provides a qualified patient, at their explicit request, with a prescription for a lethal medication that they can take on their own [6-9]. In the United States, it involves specific requirements: in the original Oregon statute and in most other state laws, the patient must be terminally ill (expected to die within six months), identified as such by two independent physicians; must be adult, competent, and a resident of the state; must have made two oral requests at least 15 days apart, plus a written request; and must be able to self-administer the lethal agent. These conditions have been slightly modified in some jurisdictions (table 3) and differ somewhat in how they are administered . In Canada, Colombia, and several European countries, terminal illness may not be required, but intolerable or unbearable suffering is required.
Where legal, the prescription is for a specific drug. Traditionally, this has been an oral barbiturate, which an appropriately licensed physician may dispense. More recently, the standard of care has been D-DMA (digitalis followed 30 minutes later by diazepam, morphine, and amitriptyline), but subsequent state Department of Health reports indicate variability in prescription practices . In the United States, the patient or a family member typically fills the prescription at a pharmacy and stores the medication until the time of use. By contrast, in the Netherlands, the physician brings the medication to the patient’s home at the time of use, and if the patient decides to postpone the intervention (for what is often a short period), the physician normally takes the lethal medication out of the house and back to their practice.
Where PAD is not legal, the patient will sometimes ask a physician to recommend, and perhaps to assist with, accessing a suitable drug or combination of drugs. There are books (eg, “Final Exit” ) and some websites (table 4) that supply terminally ill patients with information concerning end-of-life options, including information about lethal medications, the use of helium and other gasses, other methods the patient may be able to effectuate themselves, and other legally available “last-resort” options (table 5). These methods, typically used without clinical supervision, are referred to as “self-deliverance.”
Voluntary active euthanasia — Voluntary active euthanasia (VAE) differs from PAD in that the physician administers the lethal medication at the patient’s request , usually by intravenous injection of midazolam, lidocaine, and propranolol . VAE allows a response to a wider range of patient circumstances than PAD (in particular, for patients who are not physically capable of self-administration) and is more certain in its lethal effect. VAE is not legal anywhere in the United States. In countries where VAE/PAD is legal (Belgium, Canada, Colombia, Luxembourg, the Netherlands, New Zealand, and Spain), it generally requires that the patient be facing “unbearable” or “intolerable” suffering that cannot be alleviated in any way acceptable to the patient but does not require that the patient be terminally ill (ie, less than six months to live) that is part of all United States legislation. Three Australian states (Tasmania, Victoria, and Western Australia) permit VAE only when self-administered PAD is impossible. (See 'Current legal status of assisted dying' below.)
Considerations regarding PAD and VAE — In some countries where it is legal, VAE is widely considered to be morally equivalent to PAD and is subject to similar safeguards. In other countries, where VAE is not legal (eg, the United States, Australia [unless PAD is impossible], Switzerland, Germany), it is generally regarded as ethically distinct from PAD and much less socially/morally acceptable. In jurisdictions where both are legal, VAE tends to be preferred over PAD because of its reliability, efficiency, and relative absence of unwanted side effects, and because the clinician is present to confirm decision-making capacity and to respond to any unforeseen circumstances. (See 'Possible complications' below.)
In environments where both are illegal, the legal risks and psychological difficulty of VAE are greater for clinicians than for PAD because of the more direct and tangible connection between the clinician’s actions and the patient’s death. (See 'Personal and professional challenges' below.)
By contrast, patients may find VAE psychologically easier, as the clinician takes direct responsibility for the final act, albeit at the patient’s explicit request. On the other hand, some patients and families may consider VAE to be disadvantageous in that the timing of the final act may depend (to some degree) on the clinician’s availability, rather than solely on the patient and family’s preference. It can also be argued that providing PAD without offering VAE unfairly discriminates against similarly situated patients who do not have the physical abilities to self-administer (eg, patients with amyotrophic lateral sclerosis) .
CURRENT LEGAL STATUS OF ASSISTED DYING — As of May 2021, physician-assisted dying (PAD) alone is legal by statute in 11 United States jurisdictions. Ten of these have statutes with detailed eligibility requirements and safeguards: California, Colorado, District of Columbia, Hawaii, Maine, New Jersey, Oregon, Vermont, and Washington (table 6). PAD is legal in an 11th jurisdiction, Montana, by state supreme court decision, but there are no affirming statutes. PAD and/or voluntary active euthanasia (VAE) are legal in 10 other countries: Belgium, Colombia, Canada, Germany, Luxembourg, the Netherlands, New Zealand, Spain, Switzerland, and three states in Australia (Tasmania, Victoria, and Western Australia). Furthermore, top courts in Austria and Italy have declared a constitutional right to PAD, but no implementing legislation has yet been enacted (table 7).
EVOLVING LEGAL STATUS OF ASSISTED DYING — There are active right-to-die movements favoring medical aid in dying (MAID) and legal action in many, if not most developed-world nations. More than 20 United States legislatures consider bills each year. However, there is strong opposition from right-to-life and other groups. Clinicians are strongly advised to become familiar with the local and state laws governing end-of-life options where they practice, and again we caution that the legal status of all forms of MAID is a rapidly changing picture.
ADVANCE REQUESTS FOR VAE — Almost all jurisdictions permitting physician-assisted dying (PAD) or voluntary active euthanasia (VAE) require a contemporaneous request from a patient with decision-making capacity. However, Belgium and the Netherlands permit capacitated patients to complete an advance directive directing the administration of VAE at a future time when they lack capacity (eg, in late stage dementia). Due to uncertainty regarding the legitimacy of this practice in the Netherlands, regulators have provided supportive guidance [15,16]. However, very few patients receive VAE from an advance euthanasia directive. Many clinicians are uncomfortable administering VAE when the patient cannot provide contemporaneous consent or assent.
In March 2021, Canada amended its law to permit a waiver of the final consent requirement. While the patient must have capacity and otherwise be eligible at the time of request, they need not have capacity at the time of administration if they have a written arrangement with the clinician. While this goes partway to permitting advance requests, the Canadian Parliament is considering whether to allow advance requests for VAE .
EXTRALEGAL PRACTICES — Physicians should be aware of extralegal practices involving self-administered lethal drugs, often obtained over the internet, and of methods and technologies designed to provide an easy death without the assistance of a physician. The latter, which were developed by researchers in Australia, the United States, and elsewhere in response to legal opposition to physician-assisted dying (PAD), include devices such as helium hood delivery systems , the “exit bag,” rebreathing systems that use inert gases, drug combinations involving legal substances such as nicotine, and other modalities grouped under the label NuTech (New Technology in Self-Deliverance) developed in association with the Euthanasia Research & Guidance Organization (ERGO) . Helium suppliers responded by diluting the gas in party balloon tanks so that it is no longer reliably fatal, but other methods a physician may encounter are under continuing development.
UTILIZATION OF PAD AND VAE — The majority of requests for medical assistance in dying (MAID) come from patients who have cancer, although the frequency of requests for assisted dying is increasing in other terminal conditions. The predominant reason for most requests seems to have more to do with staying “in control” of the dying process and avoiding future suffering, rather than escaping from overwhelming, immediate physical suffering . Depression, hopelessness, and general psychological distress are consistently associated with initial inquiries about physician-assisted dying (PAD) and voluntary active euthanasia (VAE), but not necessarily with carrying it out [21-28].
●Patient characteristics – Oncology patients are primary utilizers of VAE and/or PAD [9,15,29-38]. In the United States, data from Oregon and Washington state indicate that approximately 72 to 77 percent of patients utilizing PAD have cancer, with the next largest group being patients with neurodegenerative diseases (approximately 8 or 9 percent) [38-40]. Annual state reports from other states show similar demographic patterns. Similarly, 2019 data from Canada indicate that 67 percent of the patients who died from MAID had cancer .
Results are comparable to those from the Netherlands and Belgium, where historically more than 80 percent of VAE and PAD cases involved patients with cancer [15,31,33,37]. However, in the Netherlands in 2015, this percentage had dropped to 72.5 percent . Similarly, in Belgium in 2013, only 68.7 percent of cases of euthanasia were for patients with cancer . By 2019, that dropped to just 62 percent [43,44].
●Reason for request – The most commonly reported reasons for a PAD request are loss of autonomy, inability to engage in enjoyable activities, and loss of dignity (table 8) [15,36,45]. Fear of uncontrolled pain is not usually a major determinant of interest in or use of PAD [20,29,36,45,46], although some studies have found a high symptom burden, including pain, in persons considering or requesting assistance in dying [21,47]. Other concerns which may prompt requests for PAD include financial burdens of treatment and fear of becoming a caregiving burden [21,24,29,36,39,46].
●Outcome – Most patients who inquire about the possibility of PAD or VAE do not follow through with a formal request, and of those who do, many do not die in this way:
•In Oregon, where PAD is legal, one in six terminally ill patients talks to their families about these issues. One in 50 asks their doctors about their willingness to provide PAD. However, only 1 in 300 patients who initially inquire about PAD dies from it . About one-third of patients who do receive a prescription do not ever take it.
•In the Netherlands in 2011, 33,900 requests were made by patients as antecedent inquiries, on average two to three requests per physician, while there were 13,400 actual requests for PAD/VAE on short notice, an average of just one per physician. Some 6.5 percent of deaths are preceded by an explicit request for PAD or VAE, but only 3.1 percent of deaths are attributed to one of these practices .
●Practices in Canada, Europe, and Australia
•In Canada, MAID (both VAE and PAD) was legalized in 2015 and formally enacted in 2016. Assistance may be provided by physicians or, in some provinces, nurse practitioners. The requesting patient must have a grievous and irremediable medical condition that cannot be reversed. They must be experiencing unbearable physical or mental suffering that cannot be relieved under conditions the person considers acceptable. Until 2021, the patient’s death had to be “reasonably foreseeable” . While already substantially more flexible than “terminal illness,” even this requirement was eliminated in March 2021. However, patients whose deaths are not reasonably foreseeable must satisfy additional safeguards .
Three further areas (requests by mature minors, advance requests, and requests where a mental disorder is the sole underlying medical condition) have been the subject of further study; final reports are available on the Council of Canadian Academies website, though further legal action has not been undertaken. In 2019, MAID accounted for 2 percent of overall deaths in Canada . Most patients with MAID deaths had cancer (67 percent); 20 percent had respiratory or cardiovascular disorders, and 10 percent had neurodegenerative diseases. Of the over 14,000 MAID deaths in Canada in the past five years, more than 99 percent were by VAE rather than PAD .
•In the Netherlands, the most recent 2019 analysis shows 4.2 percent of all deaths were the result of VAE, and 0.2 percent of deaths were from PAD . This is a slight decrease from 2015, when the total number of deaths from VAE or PAD was 4.5 percent . Compared with earlier time periods, there was a decline in the number of deaths that were the result of the use of lethal drugs not at the explicit request of the patient (life-ending acts without explicit [current] request [LAWER]; 0.7 percent in 2001, or 1000 cases, declining to 0.3 percent in 2015). The LAWER cases typically occur with a no-longer-competent patient close to death, without current request (but not necessarily without consent).
Fifty-seven percent of Dutch physicians had performed PAD or VAE at least once in their medical careers; 31 percent had done so in the past year prior to the 2015 survey.
Overall, approximately 80 percent of all deaths by PAD/VAE have occurred in cancer patients, although the proportion is declining as other diagnoses increase.
•In the Netherlands in 2019, the age distribution for euthanasia and PAD is 13 percent <60, 54 percent between 60 and 79, and 33 percent 80 years or older [15,38,52].
•In Belgium, where PAD and VAE were legalized in 2002, the situation is similar to that in the Netherlands, except there are substantially more cases of nonvoluntary euthanasia, or LAWER (ie, administering a no-longer-competent patient who is close to death a lethal dose of drugs without the patient’s concurrent explicit consent). In the most recent update from 2013, 4.6 percent of patients died by VAE, 0.06 percent by PAD, and 1.7 percent by LAWER [53,54]. In 2013, euthanasia was requested in 6 percent of all deaths, of which 76.8 percent were granted. This represents an increase over time; in 2007, euthanasia was requested in 3.5 percent of deaths, of which only 56.3 percent were granted .
In a later analysis of officially reported euthanasia cases in Belgium from 2003 to 2013, the proportion involving patients 80 years or older increased over time (from 17 to 35 percent), as did the proportion of patients who had a disease other than cancer (from 15.7 to 31.3 percent) . By 2019, these proportions grew even further. 40 percent of patients were 80 years or older, and 38 percent of patients had a disease other than cancer [43,44].
•In Germany, assisted suicide is legal for competent, uncoerced adults; euthanasia is not legal. On February 26, 2020, the Federal Constitutional Court annulled an earlier decision which held that assistance in suicide could not be “geshäftsmässig” or “like a business,” as when a provider or institution performs multiple cases; the policy was aimed at Swiss right-to-die organizations that sought to operate in Germany. This reversal made assisting a competent, uncoerced adult in suicide now legal again in Germany.
Until 2021, physician assistance in suicide was opposed by the German National Medical Association with guidelines that specifically prohibited physicians from doing so. Not all states adopted this guideline and some physicians provided PAD . Access to sodium pentobarbital is blocked by the Federal Institute for Drugs and Medical Devices at the instruction of the German Health Minister. The World Federation of Right to Die Societies remarks that some residents of Germany still travel to Switzerland for this service, some 22 persons between January 1 and May 5, 2020 .
•In the German-speaking parts of Switzerland, although PAD increased from 1.0 percent of all deaths in 2001 to 2.2 percent in 2013, the increase in continuous deep sedation was much more substantial, from 4.7 percent of all deaths in 2001 to 17.5 percent in 2013 . (See "Palliative sedation".)
•In Australia, the practice is termed voluntary assisted dying (VAD) and includes both euthanasia and assisted dying. In 2017, VAD was legalized in Victoria in limited circumstances. VAD has also become legal in Western Australia. VAD is expected to commence in Tasmania in 2022.
•VAD and PAD are now legal in New Zealand.
RESPONDING TO THE PATIENT’S REQUEST FOR ASSISTED DYING
Initial evaluation — When evaluating and responding to requests for physician-assisted dying (PAD) or voluntary active euthanasia (VAE), regardless of whether the request is for urgent or future assistance, a full evaluation should be undertaken that includes the reason for the request, the adequacy of palliative care, and the availability of alternative treatments to alleviate suffering. Hospice care should be the standard care always made available to dying patients and their families/loved ones. Alternative end-of-life options to PAD/VAE should be considered, these are outlined in the table (table 5). (See 'Potential alternatives to PAD and VAE' below.)
For patients who are asking about PAD because they are concerned about what future options they might have if their suffering becomes intolerable (eg, if they develop intractable pain, dyspnea, or severe nausea and uncontrolled vomiting), in-depth exploration of both fears and concerns is central to finding a way of responding to their request, which frequently (but not always) involves palliative options other than PAD. (See 'Inquiries about future PAD or VAE' below.)
A request for assistance in dying because of current, unacceptable, predominantly physical suffering should be treated as a medical emergency and addressed immediately and explicitly . The clinician need not immediately act upon the request for PAD or VAE if prompt attention to the patient’s suffering provides other ways of reducing distress so it is acceptable to the patient, but postponing attention or ignoring the patient’s urgent plea can contribute to even greater distress .
Comprehensive assessment of an urgent request requires time and often reveals intense emotional distress. Since a patient’s will to live may fluctuate and therapeutic options to address suffering are almost always available, an initial request should initially be met with in-depth exploration of the patient’s distress. The prescription of a potentially life-ending medication should be delayed until this careful assessment occurs. Under an exception permitted under a revision of the original Oregon statute, the two-week waiting period can be waived, but this does not preclude careful assessment. The clinician must always assure a patient who has made a request that it can be withdrawn at any time and for any reason. (See 'Urgent requests' below.)
Terms to use with patients — When working clinically, we recommend using the language used by patients and families or other loved ones, making sure to clarify exactly what they are requesting if they raise the subject or indirectly ask about it. Many will ask to be “put to sleep” or will use other euphemisms, avoiding terms like “death” and/or “suicide.” Asking patients in an open-ended way to clarify exactly what they are asking about is the proper initial response to such an inquiry or request. If a patient’s request is for “help in dying” now or potentially in the future, then forcing them and their family to use the language of “suicide” in these discussions, if it is not their chosen descriptor, is problematic for several reasons:
●The term “suicide” is often conflated in many circles with mental illness and irrationality. It may seem to imply “self-destruction,” and the act may be cast that way in some cultural and religious traditions. However, ending one’s life in situations of unbearable suffering and terminal illness may be viewed by others more as “self-preservation” than “self-destruction.”
●In the United States, PAD statutes in those states where it is legal have titles like “Death with Dignity” (eg, Oregon) or “End of Life Options” (eg, California). As noted above, no state statutes use the term “suicide” except to assert that such a death “shall not, for any purpose, constitute suicide, assisted suicide, mercy killing, or homicide under the law” [10,60].
●In European countries where PAD is legal, the practices are generally called “assisted suicide” and “euthanasia,” but these labels are not perceived in the negative sense that they are in the United States.
●In Canada, the previously used terms “voluntary euthanasia” and “assisted suicide” or “medically assisted suicide” are becoming known as “clinician-administered medical assistance in dying” and “self-administered medical assistance in dying,” respectively, and are more generally referred to as “MAiD” or “MAID” .
If a patient wants to explore these end-of-life options but associates them with punitive legal or social consequences for family members or with negative afterlife outcomes, it may be particularly important to explore mutually acceptable terminology and present other last-resort options as alternatives. (See 'Inquiries about future PAD or VAE' below and 'Urgent requests' below and 'Potential alternatives to PAD and VAE' below.)
Inquiries about future PAD or VAE — Many terminally ill patients and their family members and caregivers are concerned about what future options they might have if the patient’s suffering becomes intolerable [61,62]. Other patients are more fearful of weakness, dependency, and loss of control, and they foresee wanting to be able to control the circumstances of their own death when the time comes, such that the main issue is not as much current physical suffering but rather a desire to avoid both future suffering and the loss of control that can accompany the final stages of the dying process (table 8).
Advocates of MAID typically support such “self-determination” choices, observing that having access to the medication provides reassurance, even if it is never used; opponents often cite the “need for control” as a negative factor. Regardless of whether the request is perceived as an act of self-determination or in a more negative light, carefully evaluating requests for PAD or VAE requires considerable clinical judgment.
In such cases, the clinician may be asked to respond to a patient inquiry without full knowledge of the patient’s eventual condition or potential future intent. As part of the evaluation, as in a request for MAID or any other “last-resort” option that could end in a patient’s death right now, the clinician should ensure that the inquiry or an associated request is genuine and not influenced by mental illness, pressures or coercion, lack of insurance coverage for potentially effective treatments, or lack of access to hospice, and that the request is voluntary and originates from the patient, not from a clinician or family member .
Clinicians should use the language used by patients and families or other loved ones, clarifying exactly what is being requested if the language is unclear. (See 'Terms to use with patients' above.)
Addressing the patient’s concerns — Regardless of whether clinicians personally support or reject the option of PAD or VAE, they should openly address inquiries about assisted dying . General guidelines for responding to requests for assistance in dying are presented in the table (table 9).
The first step is to explore specifically what the patient and/or family are afraid of, with attention to what kinds of deaths they have witnessed or heard about (eg, “Tell me what you are most worried about,” “Tell me about the last phase of life experienced by your family and friends who have died”). The evaluating clinician(s) should also develop a clear understanding of why the request is coming at this time  (eg, “What is the most difficult part of your current situation?” “Was there anything in particular that made you decide to ask for this kind of help right now?”).
In-depth exploration of the fears and concerns underlying these inquiries and reassurance that clinicians will be responsive if suffering becomes unacceptable in the future are central to finding a way of responding to their request. Responses frequently (but not always) involve outlining palliative options other than MAID. (See 'Potential alternatives to PAD and VAE' below.)
Most often, clinicians can reassure the patient and family that extreme distress is not inevitable or even likely, and that palliative and hospice care is generally effective in alleviating such suffering. Nevertheless, to tell a patient who has personally witnessed severe suffering in their own life experience that this is clinically unlikely is not to address the patient’s anxieties and concerns in a responsive way. Sometimes, considering potential interventions that help patients maintain control, independence, and self-care in their home environment may be an effective means of addressing serious requests for a hastened death , but it does not supplant the need for direct attention to the request.
Clinicians should also be prepared to give patients, if asked, a realistic, unbiased, evidence-based account of what to expect in the final stages of their terminal illness. The patient and family may even need to be advised about situations in which considerable physical or psychosocial distress is reasonably foreseen (eg, severe dyspnea with end-stage heart failure or chronic obstructive pulmonary disease [COPD]). Often, reassurance about effective management strategies to prevent and/or respond to such outcomes is all that is needed. (See "Assessment and management of dyspnea in palliative care".)
However, patients should not be promised perfect symptom control where it is medically unlikely to be achievable without diminishment of cognitive function (eg, some forms of brain cancer or significant respiratory compromise). Note that “We won’t let you suffer” is often (mis)understood as “We won’t let you suffer at all” and is, in some cases, patently false . Thus, clinicians should acknowledge that there are uncommon occasions where standard measures are less than ideal, focusing on the circumstances about which the patient and family are most worried, and then describe how, together, they could approach such situations.
It is very important, and potentially reassuring, to articulate how you, as the clinician, can help in such difficult circumstances by exploring alternative “last-resort” options and clearly articulating both those options you would and those you would not feel comfortable pursuing (table 5) [6,65]. Palliative sedation may be a reassuring alternative for some (eg, those who have witnessed an undertreated, agitated terminal delirium), although not for all patients (eg, those for whom alertness and control are paramount values). The option of voluntary stopping of eating and drinking (VSED) may also be a comfort to some, although it is not always as easy to follow through with and must not be casually recommended. (See 'Potential alternatives to PAD and VAE' below.)
Besides physical distress, the patient’s suffering may include a broad range of psychosocial, spiritual, and existential factors, and every effort should be made to understand and address these aspects as well. Many of the nonphysical dimensions of suffering (eg, psychological, social, spiritual, religious, existential) may be outside the competence of the main treating clinicians, so involvement of those with special expertise (eg, psychiatry, chaplaincy, social work) is critical. (See "Psychosocial issues in advanced illness" and "Assessment and management of depression in palliative care" and "Overview of comprehensive patient assessment in palliative care", section on 'Domains of palliative assessment' and "Overview of spirituality in palliative care", section on 'Differentiating spiritual, existential, and psychological suffering'.)
Recognizing and addressing physician limitations — If, after fully exploring what hospice and/or palliative care can and cannot promise, PAD and/or VAE remain important considerations for the patient, the clinician should clearly define their approach, as well as their limitations (such as those posed by legal barriers or by personal beliefs about moral permissibility). Clinicians should forthrightly describe how they can respond to such difficult circumstances, but they should not promise what they cannot deliver, and they should not violate their own strongly held personal values, even in environments where PAD and/or VAE are legally permitted. If the patient and clinician cannot find common ground in terms of how to address these hypothetical circumstances, the patient should be helped with finding another physician for consultation or care. (See 'Personal and professional challenges' below.)
Concrete options for responding to an advance request — If the clinician is comfortable with the request and is practicing in a jurisdiction where PAD and/or VAE are legal (table 6 and table 7), and if all of the legal requirements are met, they may make a verbal commitment to provide such assistance in the future should the need arise. However, the patient may prefer to receive the medication well in advance of need, especially in jurisdictions that require waiting periods between the initial request and the provision of the medication.
Possession of potentially lethal medication may be reassuring to such patients who have satisfied the criteria for access and can take it at a time of their own choosing. Clinicians should also be aware that some patients stockpile other medications that they believe will be effective in causing death, especially in environments where PAD and VAE are not legally permitted. However, if a significant delay is anticipated between the time the legal prescription is written and when the patient plans to take it, the clinician should consider requesting a face-to-face meeting with the patient and family at a future date to ensure that all requisite criteria for access are still met. This later meeting is not legally required but is clinically recommended. Often, patients can keep the medication at the pharmacy until they are ready to use it. But if a patient who meets the criteria for PAD and receives the lethal prescription does not plan to take it right away, safe storage should also be discussed. If medications are eventually not taken and the patient dies of other causes, then family members should be counseled about safe disposal.
Clinicians must assure the patient that their request for PAD can be withdrawn at any time, whether or not the prescription has been already written, and that there is no obligation to use the medication. In Oregon, only approximately two-thirds of patients who have received a prescription actually take it . Data from other state annual reports shows the same pattern.
Clinician and/or family presence at the time the patient takes the medication is generally desirable, if the patient wishes and the physician is comfortable doing so, but physicians are not obligated to do so. Often, a hospice nurse or end-of-life group volunteer is present. If oral self-administration is to be the case, the physician should prepare the patient and family (and themselves) for the possibility that the medication may not work if not quickly and fully ingested, and they should make contingency plans for how to manage such circumstances. Such presence and contingency planning are much more safely and effectively accomplished in legal environments than illegal ones. In either situation, the physician must assure the patient that their request for PAD or VAE may be withdrawn at any time and for any reason. (See 'Possible complications' below.)
Urgent requests — Some patients request assistance in dying because of unacceptable, predominantly physical suffering, even in the face of skillfully delivered state-of-the-art-and-science palliative care treatments. Such requests should be addressed explicitly. If the patient uses a euphemism for death or refers to it indirectly, ask for clarification. Do not assume that a wish for death to come soon is a request for a lethal prescription, but do not dismiss the request either. However, in contrast to the patient requesting potential future assistance, urgent requests should be treated as a “medical emergency” , ie, not to be deflected or postponed, but addressed immediately (table 9). The clinician need not provide PAD or VAE right now if prompt attention to the patient’s suffering reveals other ways of reducing distress. However, postponing attention or ignoring the patient’s urgent plea can contribute to even greater distress.
When a seriously ill patient makes an urgent request for assistance in dying right now, as distinct from a request for potential assistance sometime in the future, this should elicit a rapid, comprehensive evaluation to be sure that the clinician understands the root cause(s) of the request. Why is the request occurring at this particular point in time, why are usual state-of-the-science palliative approaches inadequate, and why are alternative approaches (eg, intensification of symptom management, withdrawal of life-sustaining treatment, sedation for refractory symptoms) unacceptable [59,61,66,67]? In the United States, formal clinical criteria were published in 2016 by a group of experts to ensure that physicians willing to provide PAD have the guidance they need to do so in a safe and effective manner . (See 'Potential alternatives to PAD and VAE' below.)
Ideally, although not legally required, a board-certified specialist in palliative care or hospice should review the case and provide a formal consultation on an urgent basis . Realistically, however, formal palliative care consultation is not always available, so clinicians in this situation should, at a minimum, discuss the case with an experienced colleague.
Understanding the family’s concerns — In addition to exploring the patient’s concerns and preferences, meeting with close family and immediate caregivers may lead to a greater level of understanding of the patient’s current suffering, provide important perspective on the potential meaning of the request, and possibly, open options for better addressing it [69-71]. Unfortunately, not all families are sympathetic or able to work together in helpful ways in contexts such as these. A patient’s refusal to inform close family members should be thoroughly explored and understood as part of the request evaluation. Statutes such as the Oregon Death with Dignity Act require the physician to indicate whether or not the patient has informed their family; in the first 22 years of Oregon’s law, 6 percent of patients who died chose not to inform their families of their decision . The family does not have legal veto power over a competent patient’s decision to request or pursue PAD under a Death with Dignity Act. Note that almost all laws already require that the prescribing physician confirm the satisfaction of eligibility and safeguard requirements with a consulting physician.
Assessing decisional capacity — When responding to inquires or requests, either urgent or future, it is important to ensure that the patient is thinking clearly, not delirious or psychotic, and not depressed in a way that is distorting judgment, and that the request is consistent with their personal values [72,73]. (See "Assessment of decision-making capacity in adults".)
The expression of a desire for death by a terminally ill patient may raise the possibility of a mental health problem, but it is not clearly indicative of one . Not all patients making requests for a hastened death are mentally ill, and such a request cannot be taken in itself as a symptom of depression, demoralization, or mental illness.
Nevertheless, the possibility that clinical depression or anxiety or delirium may be clouding the patient’s judgment should be considered and comprehensively addressed before any “last resort” or other end-of-life decisions are made. If there is serious concern that mental illness could be a factor in the request for MAID (eg, chronic preexisting mental illness or acute psychological distress or demoralization [75,76], which could distort judgment about matters related to physical illness) or that decisional capacity may be impaired, psychiatric or psychological consultation may be legally required and should be obtained (table 3). Clinicians should be aware of the legal requirements in their state or country. In Oregon, referrals for psychiatric evaluation have averaged at approximately 4 percent of patients who later died under the law . Hawaii law requires a mental health screening for all patients requesting PAD. In other states, some institutions, eg, the University of California, San Francisco, require this even though that is not legally required .
Potential alternatives to PAD and VAE — When working with a patient who has requested PAD or VAE, either exploring it as a potential future option, if needed to avoid suffering, or requesting assistance right now, the clinician should provide a clear account of alternatives that might both reduce or avoid suffering and be consonant with the patient’s values and legal constraints. (See 'Responding to the patient’s request for assisted dying' above.)
Hospice and/or palliative care should be standard care, always available to dying patients and their families/loved ones. Hospice programs are committed to providing effective management of pain and other symptoms and to ensuring adequate patient and family support, in any setting, through the last phases of the patient’s life, including bereavement care for the family. Hospice care is typically offered when disease-directed treatments are no longer effective or acceptable to the patient and the prognosis is thought to be six months or less. Palliative care can and should be offered at any time during the course of illness. Hospice, palliative care, and PAD are not incompatible; in fact, any patient seriously considering PAD should be receiving maximal acceptable efforts at palliation before a final decision about assisting death is made. In Oregon, approximately 90 percent of patients who die under the Oregon Death with Dignity Act have had or are currently receiving hospice care . Annual reports from other states show the same thing. (See "Hospice: Philosophy of care and appropriate utilization in the United States".)
Potential end-of-life options other than PAD and/or VAE that could be explored with a patient who faces intractable suffering include (table 5):
●Intensification of pain and symptom management – If the reason for considering PAD or VAE is intractable physical symptoms, systematic increases in potentially effective palliative treatments are an appropriate option . There is widespread agreement that excellent symptom management does not accelerate death (and some evidence that it may even prolong life), but there are some circumstances where clinicians must consider the risk of unintentionally hastening death to some degree because of the need for rapid escalation of opioids and/or benzodiazepines to manage severe terminal symptoms. This is a circumstance where the “rule of double effect” may truly apply, as the clinician can foresee that the rapid escalation of palliative treatment may hasten death, but does not intend it, and the severity of the patient’s acute suffering warrants taking that risk . (See "Palliative sedation", section on 'Are we hastening death?' and "Ethical issues in palliative care" and "Ethical considerations in effective pain management at the end of life", section on 'Principle of Double Effect'.)
●Withdrawing from or foregoing life-sustaining therapy – There is a strong consensus, at least in the United States and Western Europe, about the ethical and legal permissibility of withdrawing from or foregoing life-sustaining therapy in seriously ill patients [79-83]. This is based primarily on the right to bodily integrity, ie, that patients have a right to accept or decline any potentially effective medical intervention that involves violation of their body in any way. (See "Ethical issues in palliative care", section on 'Applying principlism in palliative care'.)
Potential life-sustaining therapies that can be discontinued include both major mechanical interventions (eg, ventilatory support, dialysis, ventricular assist devices) and seemingly simple medicinal treatments (heart failure medications, insulin for type 1 diabetes, steroids for brain swelling, antibiotics, artificial fluids, and nutrition). Such “withdrawal of treatment” decisions are a common part of medical care practice and are not considered legally or ethically problematic, though some religions such as orthodox Judaism may find cessation of life-sustaining treatments, once started, morally problematic. Cessation of life-sustaining therapy requires careful management for symptom control and support during the subsequent dying process. (See "Ethical issues in palliative care", section on 'Withdrawing versus withholding treatment' and "Palliative care: Issues in the intensive care unit in adults" and "Kidney palliative care: Withdrawal of dialysis" and "Withholding and withdrawing ventilatory support in adults in the intensive care unit".)
Even when the legality of the life-ending practice is not in question, clinicians should pursue a full understanding of the “Why now?” of the decision and make certain that all palliative alternatives acceptable to the patient have been explored before activating the decision to withdraw or forego life-sustaining therapy.
●Voluntarily stopping of eating and drinking – VSED is an option for those who are still capable of eating and drinking but choose to hasten death by completely stopping both nutrition and hydration [66,84,85]. VSED is distinct from the “natural” process of gradually losing the ability to eat and drink that often accompanies the very late stages of dying. VSED requires considerable patient resolve, especially to stop drinking (appetite fades as patients become ketotic, but thirst persists and can be difficult to manage). Clinicians should play a central role in careful patient assessment before this process is initiated, and they may be needed to help palliate symptoms of oral mucosal dryness or delirium as the patient becomes dehydrated prior to death.
The dying process usually lasts 7 to 14 days from time of initiation if the patient is vigilant about avoiding all fluids. If only nutrition is refused, the dying process can extend over a much longer period of time and involve difficult issues around malnutrition. If symptoms (especially dry mouth) are not well managed, many patients may give up on the effort. VSED should never be casually recommended as a preferable alternative to PAD because it can be difficult: for the patient to sustain, for the clinician to help manage, and for the family to watch. However, there are reports that it is a gentle and easy method . (See "Stopping nutrition and hydration at the end of life", section on 'Voluntary cessation of intake'.)
●Palliative sedation – Palliative sedation is a critical last resort option for responding to otherwise very difficult to treat end-of-life suffering. There is a strong consensus about the permissibility of palliative sedation, particularly for suffering that is predominantly physical. In these cases, clinicians use the minimal amount of sedation needed to relieve the suffering. This is often called “proportionate palliative sedation.” A more extreme version, palliative sedation to unconsciousness, is a generally accepted option, especially for major end-of-life catastrophes (eg, bleeding out externally, acute agitated delirium at the end of life). Usually, but not always, artificial hydration and nutrition are not initiated or are stopped if already being utilized when palliative sedation is begun, although it should be explicitly addressed as an independent decision. (See "Palliative sedation", section on 'Other ethical concerns'.)
From an ethical standpoint, some theorists hold, under the principle of double effect, that the clinician does not “intend” death but merely “foresees” that death will occur from the attempt to relieve suffering through palliative sedation. Others challenge this distinction, asking how plausible is it that physicians could “foresee” that sedating to unconsciousness while withholding nutrition and hydration will result in death, yet not in some robust sense “intend” it [78,84]. (See "Palliative sedation", section on 'Other ethical concerns'.)
For terminally ill patients who are actively dying and in severe distress, an opportunity to obtain consent by the patient for palliative sedation may not be present. If available, the health care proxy or “next of kin” would consent on the patient’s behalf. If no health care proxy or potentially consenting family members are available and if there is no other advance directive, the provision of comfort measures (including, if necessary, the use of sedation) should be considered standard practice and the default strategy for clinician treatment decisions. This allows palliative sedation to be an option for conditions such as terminal agitated delirium, where a last resort response is sometimes needed, but the patient cannot personally consent.
Medications commonly used — If the patient’s request has been adequately documented, all requirements of the applicable law have been satisfied, and the physician is willing to assist, the physician may then write a prescription for a dose of medication that can be expected to prove lethal. Traditionally, the most frequently prescribed drugs were barbiturates, preceded by an antiemetic . The current standard of care, however, is prescribing digitalis (100 mg) to be followed 30 minutes later by diazepam (1 g), morphine (15 g), and amitriptyline (8 g) . Nevertheless, there is some variability in the drugs used . With PAD, others may prepare the drugs, but the patient must self-ingest. This is almost always orally, but some patients who cannot swallow push a plunger on a feeding tube or a rectal tube.
In the United States, a newly established professional society, the American Clinicians Academy on Medical Aid in Dying (ACAMAID), assists clinicians. A newly established service of Compassion & Choices (Pharmacist2Pharmacist) assists pharmacy professionals in providing accurate information about medications and care to patients with prescriptions for physician-assisted dying (PAD) by patient self-ingestion. Detailed information on pharmacologic action, dose, and other instructions is available in Dutch or English at the Royal Dutch Medical Association website under “News and publications” as “Guidelines for the Practice of Euthanasia and Physician Assisted Suicide.”
In the 1980s, when assisted dying was first legally tolerated under Dutch law, the Royal Dutch Pharmaceutical Association published a booklet of advice about what not to use. It recognized barbiturates as effective for oral and intravenous use but recommended against trying to induce death with benzodiazepines (inconsistent coma induction), morphine and other narcotic analgesics (uncertain because of tolerance and ineffectiveness), insulin (unpredictable outcome), and potassium chloride (painful, causes muscle spasms) .
In states where PAD is legal, most private health insurers can and do cover the cost of the medications because it is an established medical practice that meets the standard of care (although the cost of copayment varies) . Federal money (including Medicare and the Veterans’ Administration) currently cannot be used for PAD. Medicaid is a state-run program, and the decision to cover or not cover the cost of the drugs is variable among states that have authorized PAD .
Physicians whose patients are legally qualified for PAD or VAE but are unable to obtain or afford the recommended medications should beware of experimenting with substances that might produce death but might also involve unwanted side effects, such as convulsions, hallucinations, or a protracted period of dying. In such cases, the doctor-to-doctor consultation services in the United States and the Netherlands are recommended (table 4).
Triple- and quadruple-drug regimens have been developed in some states where PAD is legal, for instance by the Bay Area End of Life Options Clinic in California. Some patients attempt to import inexpensive barbiturates from foreign internet pharmacies, notably in China and Mexico, but their composition is not always reliable. Again, ACAMAID and the Doc2Doc and Pharmacist2Pharmacist consultation services are recommended.
VAE, where legal, is normally accomplished by injecting a short-acting barbiturate followed by a drug to stop the heartbeat into an existing intravenous line. Death normally occurs rapidly. In Canada, advice on drug administration is provided by the Canadian Association of MAID Assessors and Providers (CAMAP).
Advice on the correct drugs to use was first provided in the Netherlands by the Royal Medical Society in 1984 and in Belgium by the Order of Physicians in 2005. Legally required consultations by trained consultants, organized in the Support and Consultation for Euthanasia in the Netherlands (SCEN) to ascertain the use of correct drugs in the Netherlands, started in 1998; in 2010, a SCEN consultant was involved in 80 percent of the cases of VAE and PAD. In Belgium, a similar organization, the Life End information Forum (LEIF), was formed in 2003. A survey in 2009 found that, in 30 percent of the euthanasia cases, a LEIF physician-consultant was involved and that, in 52 percent of these cases, they administered the medications . This role for consultants is forbidden in the Netherlands and would also be prohibited in the United States.
Possible complications — The public perception of VAE and PAD is that they are quick, painless, and guaranteed ways to die. One challenge with self-administration of the lethal medication, as required under United States statutes, is that the short-acting oral barbiturates traditionally used had to be removed from their capsules (it would not be possible to swallow the approximately 90 capsules needed to be ingested within 30 to 120 seconds required to be effective). To be palatable within this timeframe, the capsule contents had to be mixed with a substance such as applesauce or custard to make them able to be swallowed within the required 30 to 120 seconds (they are nevertheless extremely bitter in taste).
By contrast, VAE by injection is more certain than patient-administered oral medication. For that reason, VAE is preferred by most physicians and patients in places where both are legal. In the Netherlands and Canada, where both practices are legally permitted, over 96 and 99 percent, respectively, of MAID deaths are by VAE rather than PAD.
For oral administration, an antiemetic (eg, ondansetron) is normally given at an appropriate interval in advance. In Oregon, complications such as regurgitation have been reported in 4 percent of cases, although no patient has been reported to have regained consciousness after ingesting the Death with Dignity Act medications . Initial reports from Oregon about PAD suggested that “there were no reported adverse events, although one patient who was still conscious 30 minutes after taking the lethal medication was given more of the medication to take” . Other reports from past decades have suggested complication rates of as low as under 1 percent to as high as 15 percent among PAD cases in the United States [8,29,35,45,93,94].
Where VAE is legal, minor technical problems such as inability to insert an intravenous line can occur; this is now usually circumvented by asking ambulance personnel to insert an intravenous catheter prior to the euthanasia appointment. Such problems would not be relevant in the United States, where the patient must self-administer the medication. In early data from the Netherlands, in 5 percent of euthanasia cases and 15 percent of PAD cases, the patient either did not die or took a very long time to die, and in these cases, physicians completed the process by administering further medication, converting them into euthanasia. In self-administered oral PAD, regurgitation and reawakening, although infrequent, can cause distress to family members ; these complications typically occur when the patient does not ingest the medication quickly enough or does not ingest the entire amount. It is crucial that the patient who self-administers does not fall asleep before consuming the full dose.
Information and consultation services for physicians — If a physician is considering providing access to PAD, the law in United States jurisdictions requires a second, independent opinion. Although not legally required, it is highly desirable that the second opinion or an additional consult be from someone with considerable palliative care experience, although not from someone with a principled objection to PAD in the first place. If the main treating physician is willing to assist but is not knowledgeable about prescribing and managing strategies, including recommended doses, ingestion strategies, and managing potential side effects, they may wish to contact ACAMAID or one of the doctor-to-doctor consultation services available.
In the United States, a service called Doc2Doc, provided by the advocacy organization Compassion & Choices, provides information for clinicians about a wide range of end-of-life practices, including PAD (table 4). The SCEN makes consultants available under a service provided by the Royal Dutch Medical Association; they provide support and independent consultation from expert physicians to other physicians who have received a request for euthanasia in the Netherlands . In 2016, SCEN had more than 600 qualified consultants for a population of more than 17 million people, organized in regional groups, available on a 24/7 basis, who met four times yearly for mutual consultation and continuing medical education. SCEN’s service is available in Dutch and English.
In February 2020, ACAMAID was formed to provide a patient to clinician referral system in addition to other relevant resources. In Canada, the Canadian Association of MAID Assessors and Providers (CAMAP) is a society of physicians and nurse practitioner that supports PAD and VAE assessors and providers in their work.
ETHICAL AND SOCIAL CONCERNS
Ethical arguments — General agreement has emerged about the moral permissibility of a patient refusing or discontinuing life-sustaining care, even when it means they will die, and this is now recognized in law, but disagreement persists over the ethics of physician-assisted dying (PAD) and voluntary active euthanasia (VAE).
●Proponents argue that the principle of autonomy justifies PAD and/or VAE. Autonomy, or self-determination, means that individuals have the right to pursue their own personal views of what kind of life is best, including when and how to die. Thus, to respect autonomy requires permitting individuals to weigh their own values and decide when it is better to end their lives rather than continue living in the face of terminal illness.
Opponents object that this construes autonomy too broadly and fails to take its limits into account, including challenges to the possibility of autonomy and limitation by the harm principle. The exercise of autonomy cannot include the ending of one’s own life because that would mean ending the possibility of exercising autonomy and because ending one’s own life would cause harm to others in multiple ways, including grief, loss of support, and setting dangerous precedents for others. They also point to classical writers on ethics, among them Aristotle, Thomas Aquinas, and Kant, who argued that suicide is deeply morally wrong. Proponents reply with examples of other writers on ethics, eg, Plato, the Stoics, and Hume, who did not oppose suicide in all circumstances and would not oppose it in this one.
●Second, proponents argue that the principles of mercy, nonmaleficence, and beneficence also support permitting PAD or VAE. In some cases of terminal illness, living creates more pain and suffering than death. It is also claimed that the reassurance of having the option of PAD or VAE, even if it is not used, can provide “psychological insurance” and be beneficial in the sense of relieving anxiety about the prospect of future pain and suffering.
Opponents argue that quality care for the dying is not always provided to such patients, leading to needless pain and suffering , and insist that adequate palliative care and hospice would relieve most pain and suffering. Proponents point out that, even with optimal end-of-life care, a small percentage of patients may still suffer uncontrolled pain and suffering. Opponents respond that it is unjustified to use the condition of these few patients as a justification to permit PAD/VAE for any dying patients. Proponents then reply that it is unethical to sacrifice the interests of a few persons to ostensibly serve the interests of others.
●Third, proponents argue that PAD and VAE may be considered not significantly different from terminating life-sustaining treatments, which is recognized as ethically justified. In both cases, the patient consents to hastened death, and in both cases, the physician intends to end the patient’s life to relieve their suffering and takes some action to cause this to happen; the final result is the patient’s death. If there is no difference in patient consent, physician intention, or the final result, there can be no difference in the ethical justification. (See "Ethical issues in palliative care", section on 'Requests to discontinue life-sustaining treatment'.)
Opponents counter that the distinction between intentionally ending a life and terminating life-sustaining treatments is reasonable based on the right to bodily integrity. The actual acts are different; injecting a life-ending medication or providing a prescription for one is not the same as removing or refraining from introducing an invasive, uncomfortable medical intervention. Patients who have life-sustaining interventions discontinued do not always die; some, such as Karen Ann Quinlan, live for years. (See "Legal aspects in palliative and end-of-life care in the United States", section on 'The Quinlan case'.)
Proponents respond that the physician’s intention in PAD is not malevolent; the intention is to relieve the patient’s suffering by making possible an earlier, easier death, at the patient’s earnest request, when after all, the death is already in the process of occurring. They also insist that intention is not the only relevant factor and that the line between killing and letting die is not a sharp one; many other medical strategies for negotiating death, such as removing a ventilator or discontinuing artificial hydration and nutrition, foreseeably have death as the outcome, and it is implausible to claim that the physician does not intend this. It is simply not possible to distinguish reliably between “intended” and “unintended” consequences of a given act in these circumstances.
●Fourth, opponents argue that there are potential adverse consequences of permitting PAD or VAE. The medical profession could be corrupted, or expensive or burdensome patients could be urged, nudged, pressured, or coerced into requesting death. This argument, from the potential for abuse, is often called the “slippery slope” argument. However, proponents of legalization note that there is no current evidence for this argument and that the data from jurisdictions where PAD/VAE is already legal (eg, Oregon and the Netherlands) show that it is patients of privilege who die in this way: educated, affluent, White individuals rather than individuals who are poor, disabled, less educated, or from underrepresented racial and ethnic groups. Nevertheless, the risk of abuse argument continues to play a major role in public policy argumentation.
●Fifth, results of surveys of physicians find that, even in countries where PAD is illegal, physicians receive and carry out requests to hasten death in some situations . Opponents warn that legalizing PAD or VAE may lead to further intrusion of lawyers, courts, and legislatures into the physician-patient relationship. Against this, proponents argue that legalization would bring honesty, clarity, and transparency to an existing practice.
Readers who are interested in pursuing arguments related to these controversies are referred to further sources [79,97].
Attitudes of the public and of physicians — Multiple surveys of public attitudes about euthanasia and PAD [22,98,99] reveal divisions of opinion about the morality of PAD and VAE. An article published in 2016 reviews polling data, published surveys of the public and physicians, official state and country databases, physician interviews, and other sources for the period 1947 to 2016 to portray the wide range of views about PAD and VAE . In most developed countries, public support for PAD and VAE has been relatively high over the last three decades; support is more limited among physicians .
Some studies have found important divisions along social and religious lines. Catholics and others who describe themselves as religious have been significantly more likely to oppose VAE or PAD, as have African American and older individuals [98,99]. There are also significant framing effects in the public’s response to questions about PAD and VAE based not only on how the questions are phrased but also on how the answer categories are provided [22,98,100]. For example, there is consistently less support for the practice when framed using the word “suicide” than when the same practice is described using terms like “aid in dying” or “assisted death.” In the United States, support for PAD is strongest when it concerns terminally ill patients who are experiencing severe pain.
While health care practitioners are represented on both sides of the debate over the boundaries of the physician’s role in assisting in the death of a terminally ill patient [79,97,101], one older survey found that a majority of American physicians supported the possibility of PAD in principle but that only approximately one-third said they would be willing to provide it personally, even in a legal environment . In the Netherlands, by contrast, 85 percent of physicians, similar to the general public, support VAE and PAD, and almost 60 percent of Dutch physicians have performed at least one case . In the United States, certain specialties have been more supportive than others: surgical oncologists have supported euthanasia or PAD more often than medical oncologists ; psychiatrists, obstetricians, and gynecologists have been more supportive than internists, especially oncologists [9,103-105]; family or general practitioners have been more supportive than internists. Palliative medicine specialists in the United Kingdom and Canada were found to be particularly opposed [106,107].
We caution that this is a landscape in transition and that these relative positions may shift over time.
Position statements of professional organizations — In the 1990s and early 2000s, many professional organizations issued position statements opposing PAD and VAE. The American Medical Association (AMA) Code of Ethics, for example, was understood to prohibit physician participation in assisted suicide and euthanasia on the grounds that they are “fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks” . In 2017, the American College of Physicians reiterated its opposition to PAD . Most United States state medical associations oppose legalization, although 17 have adopted neutral or supportive positions: Arizona, California, Colorado, Connecticut, Hawaii, Illinois, Maine, Maryland, Massachusetts, the District of Columbia, Minnesota, Nevada, New Mexico, New York, Oregon, Vermont, and Washington.
Some professional medical organizations, such as the American Public Health Association (APHA), support PAD with eligibility criteria and safeguards equivalent to the Oregon Death with Dignity Act and reject the use of “inaccurate terms such as ‘suicide’ and ‘assisted suicide’” . The American College of Legal Medicine and the American Medical Women’s Association has also endorsed medical aid in dying (MAID). Other professional medical organizations, such as the American Academy of Neurology and the American Academy of Family Physicians, have adopted a position of “engaged neutrality” [111,112].
Some hospice and palliative care organizations, such as the American Academy of Hospice and Palliative Medicine (AAHPM), maintain a position of “studied neutrality” on whether PAD should be legal; the AAHPM is neutral but expresses the concern that “it should not be routine medical practice” . The International Association for Hospice and Palliative Care (IAHPC) believes that no jurisdiction should consider the legalization of VAE or PAD until it ensures universal access to palliative care services and appropriate medications, including opioids for pain and dyspnea . It also supports the position of the European Association of Palliative Care (EAPC), which asserts that involuntary forms of euthanasia should not be recognized and should never be permitted . The IAHPC also supports the International Children’s Palliative Care Network (ICPCN) position, which states that “…enabling good quality of life cannot include hastening death, and we do not believe that euthanasia or physician-assisted suicide is part of children’s palliative care” . The Oregon Hospice & Palliative Care Association, by contrast, “supports the right of Oregonians to choose or not to choose any and all legal end of life options” .
The AMA, after reviewing its historical opposition to MAID, has adopted a new policy recommended by its Council on Ethical and Judicial Affairs (CEJA) . This policy points to “the irreducible moral tensions at stake for physicians with respect to participating in assisted suicide,” tensions evident in its own Code of Medical Ethics. The report notes the differing connotations of various terms (eg, “death with dignity”, “aid in dying”, vs “physician-assisted suicide”), and it notes that physicians have widely divergent but equally strongly held views: “For some physicians, the sacredness of ministering to a terminally ill or dying patient and the duty not to abandon the patient precludes the possibility of supporting patients in hastening their death. For others, not to provide a prescription for lethal medication in response to a patient’s sincere request violates that same commitment and duty. Both groups of physicians base their view of ethical practice on the guidance of Principle I of the AMA Principles of Medical Ethics: ‘A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.’”
The report is striking in its respect for views on both sides and emphasizes that physicians on either side of this debate may involve “thoughtful, morally admirable individuals” [who] hold diverging, yet equally deeply held and well-considered perspectives.
Thus, the report notes that “Opinion E-5.7 powerfully expresses the perspective of those who oppose physician-assisted suicide. Opinion 1.1.7 articulates the thoughtful moral basis for those who support assisted suicide.”
●Opinion E-5.7 – “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”
●Opinion 1.1.7 – “Preserving opportunity for physicians to act (or to refrain from acting) in accordance with the dictates of conscience in their professional practice is important for preserving the integrity of the medical profession as well as the integrity of the individual physician, on which patients and the public rely. Thus physicians should have considerable latitude to practice in accord with well-considered, deeply held beliefs that are central to their self-identities.
Noting that both of these concerns are to be found in the Code, CEJA declined to amend it and decided to retain the term “physician assisted suicide” as having the “greatest precision” and, most importantly, to clearly distinguish the practice from euthanasia. Thus, physicians who do provide assistance in dying and those who do not are understood to be acting in keeping with the provisions of the Code.
In general, professional medical associations have adopted one of about three positions:
●Opposed, primarily on the grounds that the physician is a healer and concerns about potential abuse.
●Neutral, including “engaged neutrality” encouraging conversation and debate, and acknowledging strong arguments on both sides and the need for more data.
●In favor, primarily on grounds of patient autonomy. The decision about whether to practice is left to the judgment of the individual physician, acting in the interests of the patient.
The American Association of Suicidology (AAS) has issued a statement: “the practice of physician aid in dying, also called physician-assisted suicide, Death with Dignity, and medical aid in dying, is distinct from the behavior that has been traditionally and ordinarily described as ‘suicide,’ the tragic event our organization works so hard to prevent. Although there may be overlap between the two categories, legal physician-assisted deaths should not be considered to be cases of suicide and are, therefore, a matter outside the central focus of the AAS.”
Most United States professional organizations do not provide clinical guidance on how to manage patients actively seeking assistance in dying , although some private organizations, such as Compassion & Choices and the Final Exit Network, do so. Professional clinical advice available from the Netherlands is discussed below. (See 'Information and consultation services for physicians' above.)
Again, we caution that this is a landscape in transition and that these positions may shift over time.
Concerns about abuse — Concerns about the potential for abuse of patients in vulnerable groups has played a major role in debates over legalization. A 1997 study of PAD deaths in Oregon and PAD/VAE deaths in the Netherlands examined 10 potentially vulnerable groups: older adults, women, the uninsured, those with low educational status, the poor, members of underrepresented racial or ethnic groups, people with disabilities, people with sometimes stigmatized illnesses such as AIDS, those with chronic physical or mental disabilities or chronic nonterminal illness, minors, and people with psychiatric illness, including depression and Alzheimer disease. This study found that, with the single exception of AIDS (largely based on data from before the development of potent antiretroviral drugs), the potential risks to vulnerable populations had not materialized; the majority of patients receiving PAD or VAE in both jurisdictions were comparatively well-educated, affluent, and White . The most worrisome finding, according to the author of a 2008 study of assisted deaths in Oregon, is that some patients with depression did obtain lethal prescriptions, although it is not known whether treatment for depression would have changed their outcomes . The controversial subject of PAD and VAE in patients with mental illness is covered in more detail below. (See 'Patients with mental illness' below.)
Children — Physician-assisted dying (PAD) is legal under statutes in the United States only for adults 18 years of age or older. In the Netherlands, mature and relatively mature minors are understood to have some decision-making capacity and are not excluded under the guidelines, but because they are below the age of majority, they must be regarded as “vulnerable,” and such decisions require heightened scrutiny. In the Netherlands, both PAD and voluntary active euthanasia (VAE) have been legal for minors between 12 and 16 years of age, requiring the consent of both parents. In 2020, the Netherlands extended PAD and VAE to children between 1 and 12. Belgium amended its law to allow euthanasia in minors in 2014 .
Neonates — Euthanasia in neonates is sometimes discussed in connection with PAD. In these jurisdictions, euthanasia is regarded as a practice that, although extremely rare, is sometimes the best alternative in a bad situation where an infant is so severely affected that death is likely to occur anyway.
It is legal in the Netherlands under careful guidelines, known as the Groningen Protocol [123,124], which require heightened scrutiny and the informed consent of both parents; it is also legal in Belgium. In approximately 8 percent of deaths that occurred in Dutch infants under one year of age (about 87 deaths), all in newborns with spina bifida and hydrocephalus, the decision to stop life-sustaining treatments was followed by the “use of drugs with the explicit intention to hasten death” . In 1 percent of all infant deaths (approximately 11 cases per year), drugs were administered with the intention of ending the infant’s life when the infant was not dependent upon life-sustaining interventions. In the early Belgian cases, many of the infants were born prematurely and had intracranial hemorrhages, lung hypoplasia, or severe congenital malformations .
Importantly, the Groningen Protocol explicitly concerns infants who are not on life-sustaining interventions but who have “a hopeless prognosis and experience what parents and medical experts deem to be unbearable suffering.” The authors of the protocol acknowledge that “it is difficult to define [such suffering] in the abstract.” They give children with the most serious form of spina bifida as an example of the type of patient for whom the protocol was intended.
For some, the Groningen Protocol represents the very slippery slope they warned about when they opposed legalization of VAE and PAD. For others, it constitutes humane treatment of patients who are suffering without any prospect of improvement. While it is assumed that the parents have the best interests of their child at heart, their opinions and reasoning may be at odds with that of pediatricians and neonatologists in their roles as patient advocates. There is no doubt that such decisions involve painful circumstances for the parents and physicians; euthanasia is never performed unless the parents and physicians are in agreement about what best serves the welfare of the infant perceived as suffering intolerably without hope of recovery .
In the United States, euthanasia is not permitted in adults, much less neonates. When such cases of severe suffering and poor prognosis are faced, they are usually managed by a combination of aggressive symptom management and withdrawal of potentially life-sustaining therapies, accompanied by aggressive sedation if needed.
Patients with mental illness — In the United States, death with dignity statutes require decision-making capacity; where any mental illness, including depressive conditions, that affects decision-making capacity is suspected by either evaluating physician, a psychological or psychiatric consultation is required, and a positive finding can be grounds for exclusion (table 3). Hawaii requires a mental health screening for every patient seeking PAD, not only for those with suspected impaired capacity .
In the Netherlands and Belgium, euthanasia and PAD may be permitted for patients with psychiatric disorders because not all chronic psychiatric patients are found to be incompetent with respect to a request to be helped to die. A 2015 study reviewing 66 cases of assisted dying by patients with psychiatric disorders in the Netherlands from 2011 to 2014, approximately two-thirds of them women, found that most patients had chronic, severe conditions with histories of attempted suicide and psychiatric hospitalization associated with personality disorders, social isolation, loneliness, depressive disorders (the primary psychiatric issue in 55 percent), psychotic posttraumatic stress or anxiety, or somatoform, neurocognitive, and eating disorders, as well as prolonged grief and autism . Comorbidities with functional impairments were common. The authors of the study commented that the granting of these requests appears to involve “considerable physician judgment, usually involving multiple physicians who do not always agree.” The euthanasia review committees found that one of these cases failed to meet legal due care criteria.
The Dutch criterion for assistance in dying requires intolerable suffering that cannot be alleviated by any means acceptable to the patient, and the courts have established that this is not limited to physical pain or suffering. PAD/VAE in patients with mental illness is, nevertheless, controversial. An editorial critiquing this Dutch study raises a number of concerns, among them the stability of the desire to die in some such cases, whether PAD/VAE served as a substitute for effective psychosocial intervention and support, and the fact that over one-half the patients refused at least some recommended treatment, usually on the basis of previously experienced and ineffective treatments .
There is also disagreement between physicians in general when it comes to participating in ending the life of patients with psychiatric illness [130,131]. In a 2015 survey, only 34 percent of physicians found this conceivable . Similar concerns are raised about the practice in Belgium, as well as concerns about inducing hopelessness in other psychiatric patients. The general view in the Netherlands and Belgium, however, is that the suffering involved in profound, intractable psychiatric disorders can be as severe as physical pain or suffering, and hence assistance in dying is warranted in at least some particularly difficult cases. However, others raise the possibility that some correlates of suffering in psychiatric patients (such as low income) represent societal failures, for which assisted dying should not be used .
The issue of assisted dying for psychiatric disorders is also debated in Canada , where according to the 2015 Canadian Supreme Court ruling, the right to PAD is not limited to terminally ill patients but is available to a broader group suffering from a “grievous and irremediable medical condition (including an illness, disease, or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition,” including psychiatric disorders . PAD and VAE are not available on the grounds of mental illness until at least March 2023 while a Parliamentary review is conducted .
These questions are not directly relevant in the United States, where PAD is not legal for reasons of mental illness alone, but may be indirectly relevant where a patient’s terminal physical illness is complicated by psychiatric issues that do not appear to interfere with their capacity for decision-making.
CHALLENGES FOR THE CLINICIAN
Personal and professional challenges — Health care practitioners, as well as ethicists, religious leaders, philosophers, lawyers, and laypersons with considerable palliative care knowledge, are represented on both sides of the debate over the boundaries of the physician’s role in assisting in the death of a terminally ill patient [79,97]. However, no matter where clinicians stand ethically and morally on the permissibility of physician-assisted dying (PAD) or voluntary active euthanasia (VAE), and no matter whether these practices are legally permitted or prohibited in a given jurisdiction, clinicians will still have to carefully consider and decide how they will respond to requests for assisted dying from their patients. Clinicians, ethicists, and lawmakers in different jurisdictions disagree about whether assisted dying should be reserved just for cases where excellent palliative care is insufficient to adequately relieve the suffering of a seriously ill patient, that is, as a “last resort,” or whether patients facing eventual death may choose the timing and circumstances of their own death, given their own values, preferences, circumstances, and what counts for them as the “least worst” death among those they may face, and thereby forgo much of the predictable downhill course of their disease . (See 'Urgent requests' above and 'Inquiries about future PAD or VAE' above.)
Approaches to clinician limitations — Clinicians evaluating patients who have inquired about PAD and/or VAE must be aware of their own personal boundaries. If a clinician is considering providing either PAD or VAE, whether or not permitted by law, they should fully consider the potential psychosocial and legal consequences for themselves [137,138].
Formal or informal professional consultation, preferably with someone who has significant palliative care experience, is important. In an illegal environment, it can be particularly challenging to find a trusted colleague with whom to confidentially discuss one’s potential participation before making a commitment to provide PAD or VAE to a patient and then with whom to discuss the outcome afterward. Even in a legal environment, it may be challenging to find a colleague with the right amount of experience and expertise to provide clinical consultation and support. In the United States, the American Clinicians Academy on Medical Aid in Dying (ACAMAID) is a new professional society that offers this support. Similarly, the service called Doc2Doc, provided by the advocacy organization Compassion & Choices, provides information for clinicians about a wide range of end-of-life practices, including PAD; physician information and consultation services are also available in the Netherlands. (See 'Information and consultation services for physicians' above.)
Strongly held clinician personal values that would prohibit participation in PAD or VAE should not be violated, even if the practice is legal and the patient would clearly qualify [47,139]. Nevertheless, patients for whom the possibility of PAD or VAE is important should not be “led on” by ambiguous promises to help if the clinician knows that they cannot assist. In such circumstances, clinicians who cannot help in this way should be prepared as early as possible to refer the patient to another clinician who can.
In jurisdictions where the practice of PAD or VAE is illegal, clinicians who might be willing to support the practice must consider their willingness to take a legal risk on behalf of the patient and family. If the act were ever revealed or discovered, they might be subject to legal prosecution and professional sanction. This concern sometimes drives the entire process “underground,” which generally means no second opinions or documentation, and thus, ironically, places the patient at risk for receiving inadequate counseling and support.
There are also risks for clinicians who try to protect themselves legally by having ambiguous conversations, such as “Don’t take too much of this or it will kill you” . Such conversations can easily be misunderstood. Is the clinician saying that “now is the time to call it quits”? Or is it just a warning about the dangers of the medications? Is the doctor suggesting this lethal option, offering it, or urging it? In all clinical environments, when exploring any end-of-life option, there is a need for honesty and clarity . Physicians should emphasize their commitment to the patient and, above all, that the patient will not be abandoned by the clinician, even if there is disagreement about a potential last-resort option, such as PAD/VAE or what counts for this particular patient as the “least worst” way of dying that they can foresee . If the desired treatment cannot be provided by the main treating physician for moral or legal reasons, they still have an obligation to seek common ground and a mutually acceptable approach with the patient to avoid the sense of feeling abandoned at this critical juncture .
Few studies attempt to measure the impact of participation in PAD or VAE on physicians [92,142]. When this issue was explored in Oregon seven years after legalization, physicians interviewed said they often felt unprepared and experienced apprehension and discomfort when receiving a request; these reactions stemmed from concerns about adequately managing symptoms and suffering, from not wanting to abandon patients, and from an incomplete understanding of a patient’s preferences, especially if they did not know the patient well . Some physicians report that they regret that they did not provide help to a dying patient. Physicians also reported that participating in “assisted suicide,” as the language of this study put it, required a large investment of time and was emotionally intense. They sometimes found themselves in tension with highly independent patients who were so determined that it undermined the physician’s sense of control. Nevertheless, these physicians did not express major regrets about their decisions, whether they prescribed the lethal medication or not; they said it was “the right thing to do,” even though some were uncertain about how they might respond to future requests. This study reported that going through the assisted suicide decision-making process “had a positive impact on them personally” and that it increased their capacity to discuss end-of-life issues with other patients.
Studies of PAD or VAE as a secret practice in the United States are very difficult to do . Furthermore, the associated secrecy would seem to make the decision-making and grieving process even more complex and difficult for clinicians and family members than it would be in an environment where psychological responses could be openly shared, processed, and studied .
●Several terms are used to describe physician assistance with dying (see 'Terminology' above):
•Physician-assisted dying – Physician-assisted dying (PAD) is a practice where a physician provides a terminally ill patient, at their explicit request, with a prescription for a lethal medication that they can take on their own. Other terms used to describe this practice are outlined in the table (table 1). Where legal, the prescription is for a specific drug (usually a barbiturate), which an appropriately licensed physician may dispense or for which the patient (or a family member) fills a prescription at a pharmacy. (See 'Physician-assisted dying' above.)
•Voluntary active euthanasia – Voluntary active euthanasia (VAE) differs from PAD in that the physician administers the lethal medication at the patient’s request, usually by injection. VAE is not legal anywhere in the United States; it is legal in Canada and in several European countries. It requires that the patient be facing intolerable suffering that cannot be alleviated in ways acceptable to the patient. (See 'Voluntary active euthanasia' above.)
•Medical aid in dying – The term medical aid in dying, or medical assistance in dying (MAID), as used in Canada, includes both PAD and VAE. In the United States, the term includes only PAD.
●In working clinically, we use the same language used by patients and families or other loved ones if they raise the subject or indirectly ask about it. Many will ask to be “put to sleep” or will use other euphemisms, avoiding terms like “death” and/or “suicide.” Asking patients in an open-ended way to clarify exactly what they are asking about is the proper initial response to such a request. (See 'Terms to use with patients' above.)
●As of May 2021, PAD alone is legal by statute in 10 United States jurisdictions: Oregon, Washington, Vermont, California, Colorado, Hawaii, New Jersey, Maine, and the District of Columbia. In an 11th jurisdiction, Montana, it is legal by Supreme Court decision rather than statute (table 6). PAD and/or VAE are legal in Belgium, Canada, Colombia, Germany, Luxembourg, the Netherlands, New Zealand, Spain, Switzerland, and three states in Australia (Tasmania, Victoria, and Western Australia) (table 7). New judicial rulings declaring a right to PAD have not yet been implemented in Austria or Italy. (See 'Current legal status of assisted dying' above.)
●For patients who are asking about PAD because they are concerned about what future options they might have if their suffering becomes intolerable, in-depth exploration of both fears and concerns is central to finding a way of responding to their request, which frequently (but not always) involves palliative options other than PAD. (See 'Inquiries about future PAD or VAE' above.)
●Most patients who inquire about the possibility of PAD or VAE do not follow through with a formal request, and rates of utilization of PAD/VAE are generally low. (See 'Utilization of PAD and VAE' above.)
●The majority of requests for VAE or PAD come from patients who have cancer, although the frequency of requests for assisted dying is increasing in other terminal conditions. Although many patients requesting and receiving PAD or VAE have significant physical suffering, the predominant reason for most patients’ requests seems to have more to do with staying “in control” of the dying process and avoiding future suffering, rather than escaping from overwhelming, immediate physical suffering, especially uncontrolled pain. Depression, hopelessness, and general psychological distress are consistently associated with initial inquiries about PAD and VAE, but not necessarily with practice. (See 'Utilization of PAD and VAE' above.)
●When evaluating and responding to requests for PAD or VAE, regardless of whether made urgently or for future assistance, a full evaluation should be undertaken that includes the reason for the request, the adequacy of palliative care, and the availability of alternative treatments to alleviate suffering (table 9). Hospice care should be the standard care always made available to dying patients and their families. (See 'Potential alternatives to PAD and VAE' above.)
●Alternative end-of-life options to PAD/VAE are outlined in the table (table 5); these include intensification of pain and symptom management, withholding or withdrawing treatment, voluntary stopping of eating and drinking (VSED), and palliative sedation. These alternatives should be considered whenever PAD or VAE are being contemplated in earnest. (See 'Potential alternatives to PAD and VAE' above.)
●Traditionally, the drugs that have been most frequently prescribed have been oral barbiturates, preceded by an antiemetic . More recently, physicians have been using D-DMA. They prescribe digitalis (100 mg) to be consumed 30 minutes before other medications. Then the patient consumes diazepam (1 g), morphine (15 g), and amitriptyline (8 g). (See 'Medications commonly used' above.)
●In the United States, the American Clinicians Academy on Medical Aid in Dying (ACAMAID) provides resources on pharmacology. A service of Compassion & Choices (Pharmacist2Pharmacist) assists pharmacy professionals in providing accurate information about medications and care to patients with prescriptions for aid in dying (table 4). Detailed information on pharmacologic action, dose, and other instructions is available in Dutch or English at the Royal Dutch Medical Association website under “News and publications” as “Guidelines for the Practice of Euthanasia and Physician Assisted Suicide.” (See 'Medications commonly used' above.)
●A request for assistance in dying because of current, unacceptable, predominantly physical suffering should be treated as a medical emergency. The clinician need not immediately act upon the request for PAD or VAE if prompt attention to the patient’s suffering provides other ways of reducing distress so it is acceptable to the patient, but postponing attention or ignoring the patient’s urgent plea can contribute to even greater distress. The clinician must always assure a patient who has made a request that it can be withdrawn at any time and for any reason. (See 'Urgent requests' above.)
●When responding to inquires or requests, either urgent or future, it is important to ensure that the patient is thinking clearly, not delirious or psychotic, and not depressed in a way that is distorting judgment, and that the request is consistent with their personal values. (See 'Assessing decisional capacity' above.)
●It is best to know the status of the law before fully evaluating a patient requesting access to PAD or VAE, so the evaluation can include assessment of legally required criteria. It is essential that clinicians are aware of the law surrounding these practices in their jurisdiction before finally responding to such a request (table 6 and table 7). Several services are available that provide consultation for physicians who are unsure about how to proceed, about legal constraints, and about who seeks consultation regarding a specific case (table 4). (See 'Current legal status of assisted dying' above.)
●In the United States, a service called Doc2Doc, provided by the advocacy organization Compassion & Choices, provides information for clinicians about a wide range of end-of-life practices, including PAD. ACAMAID provides similar resources.
●In Canada, the Canadian Association of MAID Assessors and Providers (CAMAP) is a society of physicians and nurse practitioner that supports PAD and VAE assessors and providers in their work. In the Netherlands, the Support and Consultation for Euthanasia(SCEN) makes consultants available under a service provided by the Royal Dutch Medical Association; they provide support and independent consultation from expert physicians to other physicians who have received a request for euthanasia in the Netherlands .
●Physicians should also be aware of extralegal practices involving self-administered lethal drugs, often obtained over the internet, and of methods and technologies designed to provide an easy death without the assistance of a physician. The latter, which were developed by researchers in Australia, the United States, and elsewhere in response to legal opposition to PAD, include devices such as helium hood delivery systems , the “exit bag,” rebreathing systems that use inert gases, drug combinations involving legal and nonlegal substances, and other modalities. (See 'Extralegal practices' above.)
●Clinicians evaluating patients who have inquired about PAD and/or VAE should also be respectful of their own personal boundaries. Strongly held clinician personal values that would prohibit participation in PAD or VAE should not be violated, even if the practice is legal and the patient would clearly qualify. In such situations, the clinician must be prepared to refer the patient as early as possible to another clinician who can help. If a clinician is considering providing either PAD or VAE where it is not permitted by law, they should fully consider the potential psychosocial and legal consequences for themselves if the act were revealed or discovered. (See 'Approaches to clinician limitations' above and 'Attitudes of the public and of physicians' above.)
●PAD is legal under statutes in the United States only for adults 18 years of age or older. In the Netherlands, mature and relatively mature minors are understood to have some decision-making capacity and are not excluded under the guidelines, but because they are below the age of majority, they must be regarded as “vulnerable,” and such decisions require heightened scrutiny (table 7) (see 'Children' above). Significant controversy surrounds the use of euthanasia for neonates and assisted dying in patients with mental illness. (See 'Neonates' above and 'Patients with mental illness' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Timothy Quill, MD, who contributed to an earlier version of this topic review.