How German palliative care physicians act at the end of life

Discussions about end of life practices in Germany have been almost taboo for over half a century, but now intense debate is underway as professional bodies review their guidelines to physicians caring for the dying. A new study out today in Palliative Medicine, published by SAGE, reveals that German physicians do hasten death in some cases, against current ethical guidelines - sometimes without sufficient patient involvement.

In light of the recent publication of a survey on German physicians attitudes towards end of life practices which had been issued by the German Medical Association and the current review of professional guidance on physicians' care at the end of life, this new study on physicians' practices at the end of life based on a postal survey of physician members of the German Society for Palliative Medicine could not be more timely.

Three colleagues at the Institute for Medical Ethics and History of Medicine at Ruhr-University, Bochum - Jochen Vollmann, Jan Schildmann and Julia Hoetzel, together with Christof Mueller-Busch, president of the German Society for Palliative Medicine, sent questionnaires to society members, and more than half responded, yielding 780 eligible questionnaires for analysis. Questions focused on treatment of the last patient under each physician's care to have died, based on a questionnaire developed by the EURELD (European end of life decision) consortium, previously used in seven other European countries.

The researchers found that physicians alleviated symptoms in 78 percent of patients and limited medical treatment with possible life shortening effects in 69 percent of cases. In 10 cases medication had been administered by the physician (9) or the patient (1) to deliberately hasten death. Those physicians with extra qualifications in palliative care were less likely to report deliberate actions to hasten death.

Competent patients were not always involved in these decisions: in 353 cases physicians described their respective patients as capable to make a decision, yet 47 of these patients were denied the opportunity to take those decisions for themselves. Physicians' explanations cited the patients' best interest, and avoidance of possible harm to the patient, all of which suggest a paternalistic approach to care.

"The findings on patients' non-involvement in decision making warrant further empirical and ethical analysis," says corresponding author, Jan Schildmann. In Germany, the Federal Court of Justice (Bundesgerichtshof) states that while limiting medical treatment and alleviating symptoms with possible life shortening consequences is lawful if it is the patient's will, it is illegal for physicians to administer substances which cause death even if the patient wants them to. Likewise the German Society for Palliative Medicine takes a clear stance against hastening death in its statutes. German Medical Association guidance outlaws assisted suicide as unethical.

"It is a remarkable finding that a relevant proportion of respondents - and even more those who have not acquired the added certificate of qualification in palliative medicine - not only foresees but also intends shortening of life as part of their practice," says Schildmann.

Although the norms of official organisations oppose assisted death, earlier surveys have suggested that a small cadre of German Society for Palliative Medicine members support it. "The gap between official norms and physicians' moral beliefs may be the starting point for an honest debate within the medical community. The data should contribute to develop
an appropriate normative and practical framework for physicians working with patients near death" says Prof. Vollmann.

Unlike many other countries, very little robust data on end of life practices among physicians in Germany exists. Ethical and clinical aspects of end of life practices have been a taboo subject in Germany, in the aftermath of patient murders witnessed under the Nazi regime.

The authors caution that while physician members of the German Society for Palliative Medicine are a relevant and interesting group to investigate, the sample is not necessarily representative for all physicians working in Germany. The authors hope that their findings will contribute to the present debate on assisted death in Germany.