The introduction of Voluntary Assisted Dying (VAD) legislation across Australia has presented challenges to clinicians, who have had to learn about new processes and, in some cases, to consider ethical and legal issues they have not previously encountered. For the most part, the adjustments have been managed smoothly, even if not all misgivings or uncertainties have been resolved. Where innovative changes are being introduced, it is important to identify and monitor concerns that arise in the community, including those of practitioners. This can be achieved by the conduct of surveys, the results of which may be used to guide further action on institutional, community and individual levels. This is especially important while the change process is getting underway, as is the case in New South Wales (NSW), where VAD legislation has only recently come into effect. The study by Light et al.1 of attitudes to VAD amongst clinicians in NSW provides such useful information. It shows – reassuringly for supporters – that most agree with the legislation. However, the value of this study is not that a majority in favour of VAD resolves the surrounding issues for all time. Rather, its main utility derives from the questions it raises but leaves unanswered and which will undoubtedly stimulate community discussion. These questions, moreover, have relevance not just for NSW but also across other jurisdictions, including Victoria, where a review of the VAD legislation is currently in progress. Light et al.'s study shows that the support for VAD amongst clinicians is not only widespread but also extends across all disciplines, even if levels of actual support vary somewhat between different areas of work, and it provides an indication of how perceptions have changed over time. Although in this case direct comparisons may be imprecise, it seems clear that acceptance of VAD amongst Australian health professionals has increased significantly over the past decade during the period in which legislation has been progressively introduced in various jurisdictions. On the other hand, it also shows that, despite such positive expressions, only a small proportion of practitioners is prepared to become directly involved, signalling potential problems for attempts to establish the expertise required to ensure the effective operation of the new system. In Victoria, this small number of participating practitioners has been shown to have an impact on the burden of care shouldered by the practitioners, as well as on the ability for patients to access their services.2 Despite the revealing nature of the figures, as with quantitative research in general, the numerical data cannot capture all consequential nuances of opinion, for which a more detailed, fine-grained analysis of qualitative investigation would be needed to fill in the details. It cannot show, for example, how or why individual clinicians make their choices, the nature of their interactions with patients and families or the impact of their experiences on their own future practice. Nor can a survey resolve ethical disagreements. This fact has not prevented polls from being used to exert political pressure on policymakers in the past: indeed, some studies have been instrumental towards this very outcome, provoking critical reflections on how the wording of a question can increase the chances of obtaining a desired outcome.3, 4 Nonetheless, the existence of a body of opinion about certain ethical issues can help clarify what is at stake and stimulate debate in affected communities. As obvious as it may sound, numerical studies cannot resolve questions of truth or ethical validity. Even widespread agreement at the level of public opinion cannot be taken as proof that a question has been, or can be, settled. High levels of unanimity cannot substitute for or circumvent ongoing, ethical discourse, in which all questions, including those claimed by some protagonists to be closed, are potentially subject to rigorous scrutiny. One of the main sources of ethical complexity about VAD arises from the multiplicity of cultural and religious perspectives within the community. Such differences can sometimes be recognised by subgroup analysis of sufficiently large quantitative data sets. However, even here, results may be misleading because responses can vary widely within population groups, which often lack homogeneity and consensus. Notwithstanding this, it is important for policymakers and health professionals to remain alert to issues of cultural sensitivity, in relation to which both principles and practices may need to be adjusted. Numerous studies have drawn attention to the array of possible concerns, which may vary according to cultural backgrounds, professional roles, religious beliefs and family contexts.5, 6 These considerations lead to an important conclusion about VAD and the ways in which it is understood, applied and evaluated. VAD is not just one thing; it is not just a piece of legislation or a single moral act. Rather, it is a focal point for a vast array of issues and concerns, ranging from the meanings attached to life and death, grief and bereavement, pain and suffering, the importance of trust, loyalty and care, and fears of abandonment and dependency. It raises questions about the relationship between law and ethics and the processes available in a society for resolving, or accommodating, ethical differences. For this reason, it cannot be summarised or evaluated in relation to just one set of variables. It is truly multidimensional, a kind of palimpsest of accumulated voices and views from multiple perspectives. For the same reason, it is worth noting that the ferment does not cease after a law has been passed. On the contrary, legislation itself should be regarded as an invitation for ongoing discussion and ethical reflection, which legislators should welcome as important for the refinement of the system. This is not always recognised, as appears to be the case at present in Victoria, where the terms of reference for the mandated review appear to have been set in a manner seeking to limit rather than stimulate public debate. So, what is the important message? That we need to continue to monitor attitudes to and beliefs about VAD, not just in the health professional community but more broadly, and to ensure that the multidimensional conversations continue. Even where VAD programmes appear to be functioning effectively, there is an unending need for ongoing review, using quantitative surveys and other research methodologies, and critical discussion. The establishment of a legal framework for VAD is not the end point: if it is successful it will open up fecund new territory within which ethical experience can continue to be deepened and enriched.
BACKGROUND: Terminally, illnesses such as cancer, AIDS, dementia, and advanced heart disease will require special supportive and palliative care, although a few numbers of these patients are provided with these services. The aim of the present study was to perform a comparative study of supportive-palliative care provision in selected countries. MATERIALS AND METHODS: This research was a descriptive comparative study that its research population was the frameworks of palliative and supportive care provision in Egypt, Turkey, America, Australia, Canada, the Netherlands, and China. These frameworks were compared across six dimensions of service receivers, financing, providers, service provider centers, type of services provided, and training. Data collection tool has included the checklist and information sources, documents, evidence, articles, books, and journals collected through the Internet and organizations related to the health information of selected countries and by the library search. Data were investigated and analyzed using the data collection tool and checklists. FINDINGS: The findings showed that the developed countries having decentralized trusteeship structure had a more favorable status in palliative and supportive care provision. The type of services provided was a combination of mental, psychological, social, spiritual, financial, and physical and communication services. Provider centers included hospital, the elderly, and cancer and charity centers. CONCLUSION: Regarding the investigation and recognition of the status of supportive-palliative care provision, it was observed that the provision of these services was a concern of the selected countries, but they did not have a defined model or pattern to provide these services. Therefore, it is suggested that each country takes a step to redesign and define frameworks and structures in the evolution of supportive-palliative cares in accordance with the particular conditions, indigenous culture, religion, and other effective cases of that country and pays special attention to the role and position of supportive-palliative cares.
The landmark report, Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines, identifies the suicide bereaved as an underserved population and recommends systematic development of peer grief support to help meet the needs of survivors of suicide loss. A widespread array of peer grief support after suicide (PGSS) services exists nationally, but only as a decentralized network of autonomous programs. Some research indicates that peer support is generally helpful to the suicide bereaved, a finding that is reinforced by a large body of emerging research showing that peer support is effective in mental illness and substance abuse recovery. The practice, study, growth, and refinement of peer support in those fields have generated viable ideas about the elements and principles of effective peer support-for individual practitioners and for programs and organizations-that could be used to guide the systematic implementation of PGSS. In addition, a comprehensive PGSS program (Tragedy Assistance Program for Survivors) that currently serves a large population-survivors of suicide in the military-could be a model for national PGSS systems development. Finally, there are several frameworks for systems development-zero suicide, consumer-operated services, recovery-oriented systems of care, and the consumer action research model-that could guide the expansion and increased effectiveness of PGSS in keeping with the Guidelines' recommendation.
A Family Conversation in Sarasota (491) I have always liked best the West Coast of Florida, with its wonderful abundance of birds, egrets, sandpiper and plunging brown pelicans. Gina's first cousin Irving and his wife Mary used to spend the winters in their condominium on Lido Key. When we met them at a restaurant there, Mary inquired about our previous visits to Florida. Last year we were in Palm Beach on business, said Gina. Tell her how you appeared in the court room with a terrible flu. Richard: Dr. MacIver sued the State of Florida, (492) he wanted to be allowed to help a patient to commit suicide but Florida's law prohibits such acts. I testified in the case. Mary: And are you for or against assisted suicide? R: I fight it. M: Why? R: Are you for? M: Once we had dinner with a nice elderly couple who later committed suicide. He was a retired doctor and she was quite senile or had Alzheimer's disease and was totally dependent on him. They were members of some kind of society. R: Hemlock. M: Yes, and them being so old and frail and as they wanted to die. I don't see why not. They invited their children and friends, had a farewell dinner, and then he gave her the pills and later took the pills himself; and they both died. To go together, that was what they wanted. R: They acted on delusion. M: What do you mean? R: They were together as long as they lived. There is no togetherness after death. Irving: You may be right, in a sense. M: But did you hear of that woman in New York who gave pills to her mother and so helped her to die? She would never have got in trouble had she not told the story. But she published a book about it and Morgenthau ... Gina: Which Morgenthau? R: The district attorney. M: Yes. He arrested her. She had to take the oath and tell how sick her mother had been, and that the mother herself had badly wanted to die. The daughter got away with it but only after this whole ordeal. R: The ordeal? Do you think one should be able to dispatch the mother, period, no questions asked? M: No, but you know ... R: And I wonder when the idea of writing a book entered the lady's mind. If this occurred to her before the act, she couldn't help minding the future book while she pondered and prepared the mother's suicide. M: That is a nasty thing to say! R: Perhaps. But the problem deserves attention. I mean, what are the real motives of family members who hasten death of a loved one? It is generally assumed that their motives can only be noble: empathy, love, desire to free the loved person from suffering. Is it always so? It is amazing that those noble explanations are unqualifiedly accepted. After all, human lives are at stake; shouldn't we be more inquisitive? M: Maybe. Still I think people should be free to choose their own death, and if they are unable to do it themselves they should be helped. You haven't yet told me why you are against it. R: No, I haven't. Remember, the law in this state prohibits helping another person to commit suicide. So I am under no obligation to justify my position. The burden of the proof is on those who want to change the status quo. But I'll try to explain my reasons. I could not expect much of your attention in the restaurant, over excellent food, with all that talk and music around us. Let's now go for a walk, and postpone the rest of the discussion till our next meeting. We haven't resumed that conversation, and now we shall not be able to do so: of the four persons, two are no longer living. The Assisted Suicide Story. Physician's assistance with suicide is all we hear nowadays, and the impression is created that this is and always has been the aim of the American right-to-die movement. It doesn't take a very long memory to know that physician-assisted suicide is a recent invention. …