"Palliative medicine is unquestionably of growing importance purely on the grounds of demographic developments, but also because quality of life as a therapeutic aim in medicine is of growing significance and is increasingly taken into account," says Prof. Dr. Franco de Conno (Honorary Director of the EAPC, National Cancer Institute, Milan, I), at the 11th Congress of the European Association of Palliative Care (EAPC), which brings together more than 3,000 experts from all over the world from May 7 to 10, in Vienna. A number of challenges have to be taken into consideration in this context. Thus an important theme for the future in palliative medicine is gentler, more ethically justifiable research to provide further improvements in palliative medical treatments, says the expert.

But this research also needs adequate financial resources. It is also essential to improve the quality and availability of palliative care at the level of training and further education. "Developing specialized education for all professions involved and a specialty within the professions, in particular for physicians, in the various European countries is an important goal. There are different levels of development in the individual countries in this respect." "The goal should be, Europe-wide, through the provision of appropriate outpatient and clinical facilities, that all people who need palliative care have adequate and prompt access to it," says Prof. De Conno at the Vienna Congress. "For the future, too, palliative care represents not only a medical but also a logistical and social challenge."

Euthanasia and physician-assisted suicide: Requests often altered if comprehensive palliative care is provided

"The stated goal of both, euthanasia and palliative care is to achieve death without suffering", says Prof. De Conno, in relation to the ongoing discussion which flares up time and again in various European countries. "Most professionals in palliative care, however, do not want to be in any way associated with euthanasia, and it remains a criminal offence in the large majority of countries."

It is recognised that within Europe several approaches to euthanasia and physician-assisted suicide are emerging and active debate surrounding this is to be encouraged, Prof. De Conno states. Research is also being conducted in the meanwhile in relation to this debate, says the expert:"Research on attitudes to euthanasia and physician-assisted suicide among professionals, patients and the wider public as well as studies of their experiences of these issues may support the wider debate. Most of these studies, however, suffer from significant methodological weaknesses raising doubts about the evidence base. A more co-ordinated approach to these studies is recommended."

Individual requests for euthanasia and physician-assisted suicide are complex in origin and include personal, psychological, social, cultural, economic and demographic factors, Prof. De Conno notes: "Such requests require respect, careful attention, together with open and sensitive communication in the clinical setting. But we have to keep in mind that requests for euthanasia and physician-assisted suicide are often altered by the provision of sufficient and comprehensive palliative care. Individuals requesting euthanasia or physician-assisted suicide should therefore have access to palliative care expertise." In addition, the provision of euthanasia and physician-assisted suicide, if considered at all and legally possible, should never be part of the responsibility of the palliative care team.

Terminal sedation is not euthanasia

There is a widespread misconception, Prof. De Conno emphasises, which confuses terminal or palliative sedation in those close to death and euthanasia - two diverse concepts that must be distinguished from each other. "Palliative sedation has the intention to relieve intolerable suffering by sedating drugs, but it is never done with the intention to kill a patient", says Prof. De Conno to clarify the difference.

Danger of pressure on individuals and devaluation of palliative care

The Italian pioneer in palliative medicine has issued an urgent warning of the dangers associated with legal moves to facilitate euthanasia: "If euthanasia is legalized in any society, then the potential exists for pressure on vulnerable persons, the underdevelopment or devaluation of palliative care structures and conflicts between legal requirements and the personal and professional values of physicians and other healthcare professionals", Prof. De Conno states. "But there is also a risk of widening of the clinical criteria of euthanasia to include other groups in society and an increase in the incidence of non voluntary and involuntary medicalized killing. Once you open the door, killing might become accepted within society."

Call for open dialogue

Within the modern medical system patients may fear that life will be prolonged unnecessary or end in unbearable distress. As a result euthanasia or physician-assisted suicide may appear as an option, Prof. De Conno acknowledges. "The Ethics Task Force encourages the EAPC and its members to engage in direct and open dialogue with those within medicine and healthcare who promote euthanasia and physician-assisted suicide", he says. "Understanding and respect for alternative viewpoints is not the same as the ethical acceptance of either euthanasia or physician-assisted suicide." EAPC should respect individual choices for euthanasia and physician-assisted suicide, but it is important to refocus attention onto the responsibility of all societies to provide care for their elderly, dying and vulnerable citizens, the expert concludes.

European Association for Palliative Care

Dr. Birgit Kofler
B&K Medien- und Kommunikationsberatung GmbH