Geriatric Unit and Clinical Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Near Dairy Circle, Hosur Road, Bangalore 560029, India.
Geriatric Unit and Clinical Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Near Dairy Circle, Hosur Road, Bangalore 560029, India.
Asian J Psychiatr. 2021 Oct;64:102802. doi: 10.1016/j.ajp.2021.102802. Epub 2021 Aug 8.
Dementias are a group of gradually progressing neurodegenerative conditions, leading to significant impairment in cognition, functioning, decision-making, capacity and autonomy. With the rise of human rights and patient-centred perspectives in psychogeriatric management, physician-assisted suicide (PAS) has emerged as an important and integral part of end-of-life care in advanced dementias.
With only few original studies in the area, this paper takes a narrative and critical approach to review the global legislations, treatment decisions, debates as well as perspectives from patients, families and medical professionals.
PAS and euthanasia are legally allowed in countries like Belgium, Netherlands, Switzerland and few states of the United States (U.S.). Germany has fewer clearer legislations in this regard. The Oregon state requirement and care criteria of the Dutch euthanasia act form the basis of most such laws. Even in the presence of these provisions, PAS is fraught with multiple medical, ethical, moral and legal dilemmas and physicians as well as caregivers are quite heterogenous in their outlook. While right to live with dignity and need to end incurable suffering form the main arguments for PAS, several arguments against it are possibility of undue influence, impaired judgement leading to biased decision-making such as depression and suicidality, inappropriate assessment of capacity, and that all deaths are not necessarily painful. These dilemmas are critically discussed in light of autonomy, decision-making and advanced directives in people living with dementia as well as the rationality of ending life and 'right to live vs right to die'. Based on the findings, certain balanced strategies are highlighted for the health professionals.
The 'slippery slope' of PAS needs to be carefully evaluated from a social justice and human rights perspective to improve dignified end-of-life care in dementia. Considerations are also discussed from India, a rapidly-ageing nation with no current provisions for PAS.
痴呆症是一组逐渐进展的神经退行性疾病，导致认知、功能、决策、能力和自主性的严重受损。随着精神老年医学管理中人权和以患者为中心的观点的兴起，医师协助自杀（PAS）已成为晚期痴呆症临终关怀的重要组成部分。
由于该领域只有少数原始研究，本文采用叙述和批判性方法，综述了全球立法、治疗决策、辩论以及来自患者、家庭和医疗专业人员的观点。
比利时、荷兰、瑞士和美国的一些州允许 PAS 和安乐死。德国在这方面的立法较为模糊。俄勒冈州的要求和荷兰安乐死法案的护理标准构成了大多数此类法律的基础。即使有这些规定，PAS 也存在许多医疗、伦理、道德和法律上的困境，医生和护理人员的观点也存在很大差异。虽然有尊严地生活的权利和结束无法治愈的痛苦的需要是 PAS 的主要论点，但也有几个反对 PAS 的论点，例如可能存在不当影响、判断力受损导致有偏见的决策，如抑郁和自杀倾向、能力评估不当以及并非所有死亡都必然痛苦。这些困境在考虑到痴呆症患者的自主权、决策和预先指示以及结束生命的合理性和“生存权与死亡权”的基础上进行了批判性讨论。基于这些发现，为卫生专业人员强调了某些平衡策略。
从社会正义和人权的角度，需要仔细评估 PAS 的“滑坡”，以改善痴呆症患者的尊严临终关怀。还从印度的角度进行了讨论，印度是一个人口迅速老龄化的国家，目前没有 PAS 的规定。
