Development and communication of written ethics policies on euthanasia in Catholic hospitals and nursing homes in Belgium (Flanders)

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Abstract

Objective

To describe whether and how Catholic hospitals and nursing homes in Belgium (Flanders) have developed written ethics policies on euthanasia and communicated these policies to their employees, patients, and patient's relatives.

Methods

A cross-sectional mail survey of general directors of Catholic hospitals and nursing homes in Belgium (Flanders).

Results

Of the 298 targeted institutions, 81% of hospitals and 62% of nursing homes returned complete questionnaires. A high percentage of Catholic hospitals (79%) and a moderate percentage of nursing homes (30%) had written ethics policies on euthanasia. Both caregivers and healthcare administrators were involved in the development and approval of these policies. Physicians and nurses were best informed about the policies. More than half of the nursing homes (57%) took the initiative to inform both residents and relatives about the policies, while only one hospital did so.

Conclusion

The high prevalence of written ethics policies on euthanasia in Flemish Catholic hospitals may reflect the concern of healthcare administrators to maintain the quality of care for patients requesting euthanasia. However, the true contribution of these policies to quality end-of-life care and to supporting caregivers remains unknown and needs further research.

Practice implications

Legislation and centrally developed guidelines might influence healthcare institutions to develop ethics policies.

Introduction

Worldwide, caregivers in hospitals and nursing homes are confronted with patients requesting euthanasia, regardless of the existence of laws governing it. Of all deaths, euthanasia accounts for 1.70–2.59% in The Netherlands, 1.70% in Australia, 0.30–1.20% in Belgium (Flanders), 0.27% in Switzerland, 0.06% in Denmark, and 0.04% in Italy [1], [2], [3], [4]. The lack of clarity and communication in healthcare practice about how to care for patients requesting euthanasia is worrisome [1], [5]. There is a growing awareness that healthcare institutions bear significant responsibility in maintaining the quality of care for their patients at the end of life – including those who request euthanasia – and in supporting their caregivers [6], [7]. To take on this challenge, a first step for institutions would be to develop a written ethics policy on euthanasia and to adequately communicate this policy to caregivers, patients, and relatives [8], [9], [10].

In 2002, Belgium became the second country after The Netherlands to enact a law on euthanasia [11]. This law allows euthanasia only under strict conditions and to be performed only by physicians [11]. During the period preceding the enactment of this law, the Belgian Senate organized public hearings to address various issues regarding euthanasia. Flemish Catholic healthcare institutions played a significant role in these hearings by directing attention to the importance of good palliative care for patients requesting euthanasia [8], [12]. Caritas Flanders, the umbrella organization that promotes collaboration among Catholic healthcare institutions in Flanders, drafted a position paper, “Caring for a dignified end of life,” [8] together with a clinical practice guideline, “Facing requests for euthanasia” [13]. On 17 May 2002, the day after the Belgian parliament passed the Act on Euthanasia, the position paper and the clinical practice guideline were sent to all Catholic healthcare institutions in Flanders, together with the call to develop proper institutional ethics policies on euthanasia. By disseminating these two documents [8], [13], Caritas Flanders has attempted to improve the clarity of euthanasia ethics policies and the communication of these policies to caregivers, patients, and their relatives.

To date, concrete data remain unavailable concerning written ethics policies on euthanasia in Flemish Catholic healthcare institutions. The lack of relevant data prompted us to undertake the present study. The first part of our study investigated the content of written ethics policies on euthanasia in Catholic healthcare institutions [14]. Here, we describe the results of the second part of our study, which examined whether and how Flemish Catholic hospitals and nursing homes have developed written ethics policies on euthanasia and whether they have communicated these policies to others. Specific objectives of the study were to describe the following:

  • The prevalence of written ethics policies on euthanasia in these institutions;

  • The reasons why ethics policies on euthanasia were or were not developed by these institutions;

  • The parties involved in the development and approval of ethics policies on euthanasia in these institutions;

  • Whether the ethics policies were made known to stakeholders of these institutions.

Section snippets

Catholic healthcare institutions and euthanasia in Belgium (Flanders)

The study was carried out in Flanders, the Dutch-speaking part of Belgium, where 60% (5.9 million inhabitants) of the population lives. The majority (81%) of the Flemish population is Roman Catholic. Catholic hospitals and nursing homes represent 56% (47/84) and 33% (251/761), respectively, of the total number of hospitals and nursing homes in Flanders.

Like other organizations, in recent years Catholic healthcare institutions have undergone the influence of social trends such as the rise in

Design

A cross-sectional, descriptive survey was used. The study was conducted as part of a larger survey examining the ethics policies on end-of-life decisions in Catholic hospitals and nursing homes in Belgium (Flanders).

Sample

All Flemish Catholic hospitals and nursing homes received the postal questionnaire by mail. We obtained the addresses of these institutions from 1 January 2003 member list of Caritas Flanders, an organization that assembles all Catholic healthcare institutions in Flanders. We mailed

Response

Of the 298 institutions surveyed, 65% (194) returned a completed questionnaire. The response rate from hospitals and nursing homes was 81% (38/47) and 62% (156/251), respectively. A number of institutions opted to reveal their identity when returning the questionnaire. This made it possible to determine the geographical location of 76% (29) of the participating hospitals and 66% (103) of the participating nursing homes. These institutions were distributed throughout all five provinces of

Discussion

In interpreting the data of this study, it is necessary to consider some methodological issues. First, the overall response rate in our survey was 65%, which is satisfactory for survey research [23]. Response rate from hospitals (81%) was high. Because all Catholic hospitals in Flanders were invited to participate in the study and because all provinces of Flanders returned questionnaires, we consider these results to be representative of all Flemish Catholic hospitals. Response rate from

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    • Psychiatric patients requesting euthanasia: Guidelines for sound clinical and ethical decision making

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      For an overview of the operationalisations of the substantive and procedural legal criteria, and of the additions to the procedural legal criteria recommended by the guidelines, see Tables A and B. In the 16 years since the adoption of the Belgian Euthanasia Law, the number of cases of euthanasia for psychological suffering involving psychiatric patients has significantly increased, as has the number of healthcare organisations (e.g. hospitals and nursing homes) that have developed and implemented written clinical-ethical policies on the management of such requests (Gastmans, Lemiengre, & de Casterlé, 2006; Lemiengre, Dierckx de Casterlé, Denier, Schotsmans, & Gastmans, 2008, 2009; Lemiengre, Dierckx de Casterlé, Schotsmans, & Gastmans, 2014). One guideline (I) that we have analysed is an example of such a protocol, in that it is describing a transparent procedure to be followed for requests of euthanasia for psychological suffering.

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