Euthanasia: Approve without knowing

Gonzalez Pineda, Bernat; Villaró Pellejero, Carolina Rossana; Solsona Duran, José Felipe
doi:10.1016/j.medcle.2020.04.030
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Interest in euthanasia has grown in importance over the last few centuries&#46; In a doctoral thesis&#44; Karl Friedrich Marx argued the need to teach doctors how to care for the terminally ill in a professional and humane way&#44; because they are not able to give them athanasia&#44; that is&#44; immortality&#46; This is why his disciple&#44; Heinrich Rohlfs&#44; gave euthanasia the status of an independent medical discipline on a par with diagnosis&#44; therapeutics or surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Euthanasia is a word derived from the Greek term <span class="elsevierStyleItalic">Eu-Thanatos</span> &#40;good death&#41;&#46; It refers to those actions carried out by other persons&#44; at the express and repeated request of a patient who suffers physical or psychological distress as a consequence of an incurable disease and who lives with an unacceptable&#44; unworthy&#44; and irreversible illness&#44; with a poor prognosis and suffering&#44; in order to cause his or her death quickly&#44; efficiently&#44; and painlessly&#46; These actions are done in consideration of the person and in accordance with his or her will&#44; an essential requirement to distinguish from homicide&#44; in order to end or avoid unbearable suffering&#44; with a direct and immediate causal link between the action taken and the death of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Today&#44; death is gradually starting to cease to be considered a taboo subject&#46; As a society&#44; we are beginning to ask ourselves questions around this biological&#44; physiological&#44; and spiritual process of life to the point of considering the option of legalising euthanasia&#46; Choosing how we die<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> takes on importance&#44; emphasising the option of having an advance directives document to anticipate the final event&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In addition&#44; there is a trend towards change in recent years with regard to decisions to limit life support treatment&#44; moving to less invasive and aggressive options&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It should be noted that&#44; in Spain&#44; only half of the patients who need palliative care receive it&#44; and 60&#44;000 people die each year with avoidable intense suffering as a result of not receiving adequate care&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Euthanasia is officially accepted in some countries&#44; where it has been legalised or decriminalised&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In Spain it is illegal despite the many parliamentary debates held to address this issue<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and the surveys carried out among citizens to find out their opinion on the matter&#44; with very favourable results towards its acceptance&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> as well as among health professionals who have been asked about the different situations in which they have found themselves throughout their careers in relation to terminally ill patients&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Despite the opposition of the Popular Party and Vox&#44; in February 2020 the Congress of Deputies admitted the proposal for an Organic Law on the Regulation of Euthanasia&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Sanders and Chaloner<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> insist that&#44; despite being a much-debated topic in the media and by the general public&#44; there seems to be a lack of clarification on the concepts and definitions used in the social debate on euthanasia&#46; Moreover&#44; not only medical criteria are involved&#44; but also cultural and socio-economic criteria that may vary according to the doctor&#8217;s and the patient&#8217;s values&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">From the aforementioned surveys&#44; we conclude that the population&#44; when speaking on the subject&#44; knows the real meaning of the term&#46; This conclusion is wrong&#58; the surveys carried out are very superficial&#44; asking only whether people agree to a dignified death&#44; thus encompassing different concepts&#46; The following concepts stand out&#58; withholding&#47;withdrawal of life support &#40;WLS&#41;&#44; which implies the acceptance of the irreversibility of a disease and the convenience of abandoning the treatments that aim to extend life&#44; maintaining only the necessary therapies to guarantee the maximum well-being of the patient&#44; always at the request of the patient or relatives&#44; advised by the doctor&#59; the non-initiation or withdrawal of life support treatment&#44; which is part of WLS and consists of not initiating or withdrawing treatments&#44; such as mechanical ventilation&#44; cardiopulmonary resuscitation&#44; dialysis&#44; artificial nutrition &#40;enteral and parenteral&#41; or hydration &#40;in unconscious situations&#41;&#44; when an acute complication occurs at the end of an incurable disease with the aim of facilitating the course of the disease towards death without unnecessarily prolonging the agony with invasive treatments&#59; terminal sedation&#44; consisting of the administration of drugs to achieve the relief of physical and&#47;or psychological suffering&#44; which cannot be achieved by other measures&#44; by means of a sufficiently severe and foreseeably irreversible decrease in consciousness&#44; in a patient in whom death is imminent and with implied&#44; explicit or delegated consent<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#59; the shortening of the dying process&#44; based on the administration of sedatives at doses higher than the usual ones in patients who are at the end of life with the clear and specific objective of accelerating the final process of the patient&#8217;s life<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#59; and finally assisted suicide or suicide assistance&#44; the action of a person who suffers from an irreversible disease to end his life and who has the help of another person who provides him with the knowledge and means to do so&#46; When the person helping is the doctor himself&#44; we speak of medically assisted suicide&#46; In assisted suicide&#44; the transitory nature of the act is reduced to a minimum&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Should euthanasia be legalised&#44; a law would have to be drafted by the government and passed by a majority in parliament&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Consequently&#44; politicians should have a clear understanding of the concept of euthanasia&#44; as should citizens&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Apart from citizens&#8217; and politicians&#8217; knowledge of these issues&#44; this research&#44; which is the result of a Final Degree Project&#44; has sought to investigate another issue&#46; Even more so than these two groups&#44; there is another group with an obligation to have a clear understanding of the terminology we are dealing with&#58; health professionals&#46; They would be part of that minority of society responsible for actively carrying out and practising euthanasia from the front line&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Our objective is to find out the degree of knowledge that healthcare professionals in a university hospital have about euthanasia&#44; mainly by surveying doctors&#44; as it is understood that these would be the healthcare professionals who would act as the main players in carrying out this action&#46; Our hypothesis is based on the fact that less than 5&#37; of health professionals are aware of the full meaning of euthanasia&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We place special emphasis on Oncology&#44; Intensive Care&#44; Emergency and Anaesthesia departments&#44; carrying out a more exhaustive analysis of these 4 departments compared to the rest&#44; since we consider that professionals in these specialties should be more familiar with euthanasia as they are most likely to deal with patients requesting it&#46; Both the medical and nursing professionals of these hospital departments were evaluated&#46; The latter maintain a closer relationship with patients&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">As for other hospital departments&#44; only medical personnel are evaluated&#46; Of these&#44; we differentiate between attending and residents&#46; We assume that the latter have a higher degree of knowledge as they have taken the subjects of Bioethics and Legal and Forensic Medicine&#44; which provide compulsory and more up-to-date instruction on these subjects&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Material and methods</span><p id="par0060" class="elsevierStylePara elsevierViewall">A survey was designed with 5 options in which 5 end-of-life processes were described&#46; The objective of the health professionals was to choose those that&#44; according to their criteria and knowledge&#44; described a situation where euthanasia was applied&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Of these&#44; the first 4 corresponded to 4 clinical cases&#58; the first described a procedure for not initiating or withdrawing life support treatment&#59; the second&#44; the terminal sedation requested by the patient&#59; the third&#44; the shortening of the dying process&#59; and the fourth&#44; assisted suicide or suicide assistance&#46; The fifth answer stated that none of the above options corresponded to a euthanasia process &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0035">B</a> attached&#41;&#46; The correct option was the last one&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The study was approved by the Healthcare Ethics Committee &#40;HEC&#41; as well as by the Clinical Research Ethics Committee &#40;CREC&#41; of the university hospital&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A pilot study was previously carried out with 90 healthcare professionals to find out the sample size that would be required to obtain the appropriate confidence intervals&#46; A result of less than 5&#37; was found&#44; and it was calculated that the sample needed to estimate confidence intervals of 1&#37; was 450 doctors&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">There were also nursing professionals from the 3 aforementioned departments&#44; corresponding to a total of 178 workers&#46; Of the latter&#44; the sample needed to find the same result with confidence intervals of 1&#37; was 163&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The survey was answered in the hospital medical departments when they held their regular clinical sessions&#44; a time when the largest possible sample could be obtained&#44; meaning a greater representation of each department and of the hospital as a whole&#46; Regarding the nursing staff&#44; the survey was answered by morning shift workers during rest periods&#46; Health professionals answered the survey individually and anonymously at the time it was distributed&#44; and it was collected immediately upon completion&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Once the results were obtained&#44; the prevalence of professionals who had chosen the correct option&#44; with their confidence intervals&#44; was calculated with Fisher&#39;s exact method&#44; using OpenEpi software&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The descriptive and cross-sectional study was carried out from September to December 2016&#46; During the first 3 months the information was collected through the surveys and the results were analysed in the last month&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">The university hospital where the study was conducted consisted of 1130 professionals&#44; of whom 596 were doctors &#40;attending and residents&#41;&#46; 307 medical professionals from the departments shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> were surveyed&#46; Regarding nursing professionals&#44; 52 of those surveyed belonged to the Intensive Care&#44; Emergency and Oncology departments&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Of the 307 doctors surveyed&#44; the results obtained are those observed in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#58; the first option of the survey&#44; withholding or withdrawal of life support treatments&#44; was chosen by 204 doctors&#59; the second option&#44; terminal sedation requested by the patient&#44; 84&#59; the third&#44; shortening of the dying process&#44; by 160&#59; the fourth&#44; assisted suicide or suicide assistance&#44; 159&#59; and the fifth was selected by 12&#44; of which 6 were attending and 6 residents&#46; It should be remembered that the sum of the number of total responses is higher than the sample of surveyed doctors because they had the option of choosing more than one response&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Twelve doctors chose the correct option&#44; the fifth&#46; This result has a percentage translation that corresponds to a 3&#46;908&#37; correctness with 95&#37; confidence intervals of 2&#46;25 and 6&#46;707&#37;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">69 doctors from the 4 departments closest to the type of patient who may be most likely to request euthanasia &#40;Oncology&#44; Intensive Care&#44; Emergency and Anaesthesia&#41; were surveyed&#46; The results are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#58; the first option was chosen by 52 doctors&#59; the second by 12&#59; the third by 37&#59; the fourth by 36 and the fifth by 2&#44; corresponding to an attending and a resident&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Only 2 doctors chose the correct option&#44; representing a 2&#44;898&#37; correctness with 95&#37; confidence intervals of 0&#46;798 and 9&#46;966&#37;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Finally&#44; of the 52 nursing professionals from the Intensive Care&#44; Emergency and Oncology departments surveyed&#44; the results obtained are those shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#58; the first option was chosen by 44 professionals&#59; the second by 17&#59; the third by 28&#59; the fourth by 22 and the fifth by 0&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The corresponding percentage of correctness is 0&#37; with 95&#37; confidence intervals of 0 and 6&#46;878&#37;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The same pattern is maintained in the 3 graphs&#58; the first option&#44; withholding or withdrawal of life support treatments&#44; is by far the most popular choice for most health professionals&#59; the second option&#44; terminal sedation requested by the patient&#44; is the one that fewer professionals choose from the first 4&#59; both the third&#44; shortening the dying process&#44; and the fourth&#44; assisted suicide or suicide assistance&#44; have a similar degree of choice&#46; Finally&#44; the fifth option is the least chosen by far compared to the others&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">There are studies that have evaluated the opinion of citizens and health professionals regarding euthanasia&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;10&#44;16</span></a> Others suggest a lack of consensus on the concept of euthanasia&#44; confusing it with bringing death forward&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">However&#44; until this research was carried out&#44; the degree of knowledge of the different healthcare professionals had never been assessed with clinical cases of different vital terminal processes&#46; The health professional must know what euthanasia is&#44; know its illegality and must not confuse it with other legal processes&#44; especially with the misnamed passive euthanasia&#44; so as not to find themselves in the situation of ceasing to offer all appropriate medical procedures&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The literature refers to the misnamed passive euthanasia as the administration of drugs that are known to precipitate the death of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> It should be made clear that it is not always for this purpose that drugs known to precipitate death are given&#46; The phrase&#44; together with the terminology used&#44; is incorrect&#46; It does not describe active euthanasia&#44; a term that should no longer be used because active is an intrinsic characteristic of euthanasia&#44; but terminal sedation&#44; which is directly aimed at relieving suffering and not causing death&#46; We emphasize that euthanasia seeks quick&#44; effective&#44; and painless death&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In reference to the present study&#44; with the results obtained&#44; the hypothesis initially raised cannot be verified&#46; The initial percentages do confirm the hypothesis&#44; but the con&#64257;dence intervals encompass and exceed the established threshold&#46; Even so&#44; we consider that the results obtained are clinically relevant and of great significance&#46; An exceptionally low percentage of healthcare professionals&#44; less than 10&#37; considering the confidence intervals&#44; are aware of this subject&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">There is a great tendency to confuse euthanasia with withholding or withdrawal of life support treatments&#44; which is reflected in the results&#46; This is a rather surprising confusion&#44; as this practice is completely legal in our country&#46; This mistake can lead to undesirable situations in which a terminally ill patient is denied this right simply because it is mistaken for euthanasia&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">To a lesser extent&#44; there is confusion with the terminal sedation requested by the patient&#46; It is a compassionate&#44; legal sedation and considered basic in the treatment of a terminal patient&#46; The consequences of this confusion could lead to a scenario where the patient is suboptimally sedated for fear of committing an illegal act&#44; causing great suffering&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In equal proportion there is confusion with the family&#8217;s request to shorten the dying process and assisted suicide&#46; The first is clearly illegal&#44; as the aim of sedative medication is to bring about the death of the patient and not to alleviate suffering&#46; In addition&#44; this process is requested by the family and not by the patient himself&#44; unlike euthanasia&#44; thus being considered a homicide&#46; As for assisted suicide&#44; which is also illegal&#44; the transitory nature of the act is reduced to a minimum&#44; as it is the patient who takes the last step to end his or her life&#46; It is the situation most easily confused with euthanasia&#44; where the only difference is that the last action is never performed by the patient&#46; For this reason&#44; and in our opinion&#44; assisted suicide could be considered more acceptable&#44; morally speaking&#44; more likely to be consented to by society and to be legalised&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The results obtained are quite worrying due to the professional profile involved&#44; who are required to be familiar with bioethical issues&#44; among which the one surveyed stands out&#46; The low percentage obtained in the Intensive Care&#44; Emergency&#44; Oncology and Anaesthesia departments stands out&#46; These services are the ones that&#44; in a hypothetical future in which euthanasia were to be decriminalised or legalised&#44; would receive more patients likely to request it&#46; The Internal Medicine and Geriatrics departments&#44; despite not having been studied so thoroughly in this study&#44; would also form part of the latter group&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">There are no differences between residents and attending doctors&#58; of those who have answered the survey correctly&#44; 50&#37; are attending and 50&#37; are residents&#46; We therefore conclude that the fact of having completed their degree and having studied Bioethics and Legal and Forensic Medicine&#44; where these concepts are taught in a more up-to-date and mandatory way&#44; has not been reflected in their response to the survey&#46; It should be noted that Bioethics is a compulsory subject only in the last three years&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Lack of time and resources for data collection and analysis has been an important limiting factor in obtaining the optimal sample of medical professionals&#46; The same happened with regard to nursing professionals&#44; where only those on the morning shift could be surveyed&#44; as well as the Anaesthesia department&#44; which was not surveyed&#46; Of an ideal sample of 450 medical professionals&#44; 307 were surveyed and of 163 nursing professionals&#44; 52&#44; with a total of 359 professionals surveyed&#46; This fact has led to broader confidence intervals than expected&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Among other limitations is the fact that it corresponds to the knowledge of a single university and teaching hospital&#44; and the results obtained cannot be extrapolated to other health areas&#46; More studies are needed in different hospitals to generalize our hypothesis&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Another possible limitation could be an incorrect understanding of the terms of the survey&#46; In order to minimise this situation&#44; one of the authors of this study was always present during the course of the study to clarify possible doubts&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The methodology used comprises a single question scheme and a non-randomised selection of the sample&#46; Consequently&#44; the degree of awareness of the term euthanasia cannot be determined with absolute certainty&#46; Besides not being validated&#44; the survey does not discriminate against all knowledge&#46; However&#44; we do not dispute the validity of the results obtained as they suggest that even in the most pro-knowledge situation&#44; the correct score would not have exceeded 10&#37;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">We believe that the freedom to choose more than one answer carries a higher level of demand when it comes to knowledge&#46; The healthcare professional is used to answering multiple-choice questions in the understanding that there is only one correct answer&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">We consider that the existence of a fifth option that overrides all the previous ones solves the problem that would arise if all the options were clinical cases&#46; The professional would arrive at the correct answer without a good knowledge of the term studied&#46; In other words&#44; he would arrive at the correct answer by discarding the options that he knows for sure do not correspond to euthanasia&#46; This fifth option aims to ensure that the correct answer is chosen on the basis of one&#39;s own knowledge and not due to external factors&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">We use this survey delivery and collection methodology because we consider it the safest way to avoid plagiarism and the most efficient way to get the maximum possible sample&#58; everyone who has the questionnaire completes it&#46; Other survey delivery and collection methods did not ensure that all completed surveys were collected&#44; thus obtaining a lower&#44; less representative&#44; and more biased sample&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">We want to emphasize that the essence of the problem is not a &#8220;sensu stricto&#8221; medical-health issue&#44; but an ethical-moral and health policy issue&#46; The doctrine of double effect states that an action with two or more possible effects&#44; including at least one good and one bad is morally permissible if it is not immoral&#44; if the good effect is not achieved through a bad one&#44; and if the positive consequences outweigh the negative ones&#46; In order to qualify an action as ethically correct&#44; this doctrine requires the fulfilment of all the conditions&#44; without exception&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">For the resolution of ethical conflicts&#44; first of all&#44; the facts must be clear&#46; Only with a thorough knowledge of these&#44; one is able to discuss the moral issues that are so important in our society today&#46; This is what the ethical conflict resolution method tells us&#44; as a premise before any evaluation&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">In conclusion&#44; our study suggests a lack of awareness of euthanasia among health professionals&#44; with the concept being confused mainly with withholding or withdrawal of life support&#46; Consequently&#44; education and training in bioethics for healthcare professionals should be promoted&#44; especially through ethics committees&#44; which are essential for the resolution of conflicting situations in routine clinical practice&#46; The manifest lack of knowledge on the subject can also help policy makers and politicians to gain a deeper understanding of the issue in order to set priorities&#46; It should always be remembered that we are in a plural and democratic society in which different ideological views coexist and where it is not possible nor should it be possible to define or impose an ethical code valid for all&#44; which would lead us to a form of totalitarianism&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> In the same way&#44; a better education for the population is also required&#44; prior to conducting any survey&#46; Only then will we be up to the moral standards that society requires of healthcare professionals&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Finally&#44; we consider that&#44; in view of a possible future legalisation&#44; the application mechanism and the convenience of the patient being assessed by an independent team to confirm his or her freedom and autonomy must be of paramount importance&#46; Having a territorial clinical decision-making committees would be an additional decision-making help in the same way as it is done in tumour committees or other committees for situations of high clinical complexity&#46; Based on results from countries where euthanasia has been legalised&#44; there has been no increase in the number of euthanasia cases&#44; nor has the end-of-life decision-making process been less adequate&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interests</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare no potential conflict of interest with respect to the research&#44; authorship and&#47;or publication of this article&#46;</p></span></span>"
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                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anaesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intensive Care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oncology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paediatrics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rheumatology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nephrology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dermatology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gynaecology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pneumology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Digestive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Internal Medicine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Otolaryngology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">General Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neurology and Neurophysiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Infectious&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anatomical pathology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Endocrinology and Nutrition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Haematology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Orthopaedic Surgery and Traumatology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Psychiatry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Miscellaneous &#40;Geriatrics&#44; Family&#44; Vascular Cir&#44; Thoracic Surg&#46;&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">307&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                      "titulo" => "Eutanasia hoy un debate abierto"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Barbero Guti&#233;rrez"
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                            2 => "A&#46; Couceiro Vidal"
                            3 => "M&#46; Gasull Vilella"
                            4 => "E&#46; Gimbernat Ordeig"
                            5 => "M&#46; G&#243;mez Sancho"
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                      "titulo" => "Informe sobre l&#8217;eutan&#224;sia i l&#8217;ajuda al su&#239;cidi&#46; Comit&#232; Consultiu de Bio&#232;tica de Catalunya &#40;Departament de Salut&#46; Generalitat de Catalunya&#41;"
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                            2 => "M&#46;A&#46; Broggi"
                            3 => "V&#46; Camps"
                            4 => "R&#46; Espasa"
                            5 => "J&#46; Hern&#225;ndez"
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                  "referenciaCompleta" => "Col&#183;legi de Metges de Barcelona&#46; La asistencia a personas en situaci&#243;n de final de vida&#59; 2019 &#91;Accessedo 27 February 2020&#93;&#46; Available from&#58; <a target="_blank" href="https://www.comb.cat/Upload/Documents/8045.PDF">https&#58;&#47;&#47;www&#46;comb&#46;cat&#47;Upload&#47;Documents&#47;8045&#46;PDF</a>&#46;"
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                            3 => "I&#46; Perez Mart&#237;n"
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                            3 => "E&#46;L&#46; G&#243;mez-Dur&#225;n"
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                      "titulo" => "Informe sobre l&#8217;eutan&#224;sia i l&#8217;ajuda al su&#239;cidi&#46; Comit&#232; Consultiu de Bio&#232;tica de Catalunya &#40;Departament de Salut&#46; Generalitat de Catalunya&#41;"
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