Assisted suicide



Assisted suicide is the common term for controversial actions by which an individual helps another person die upon their wanting to do so&mdash;a concept almost always reserved for people who are terminally ill. "Assistance" may mean providing one with the means (drugs or equipment) to end their own lives, but may extend to other actions. The current waves of global public debate have been ongoing for decades, centering on legal, religious, and moral conceptions of "suicide" and a personal "right to death". Legally speaking, the practice may be legal, illegal, or undecided depending on the culture or jurisdiction.

The terminology "assisted suicide" is itself controversial due to the connotations of self-destruction and despair associated with the term "suicide." Some proponents prefer the term "voluntary euthanasia" for assisted suicides made in good faith with both moral and spiritual beliefs, and reserve the term "suicide" for acts committed out of more self-destructive impulse. In some cases, the terms aid in dying or death with dignity are preferred.

In religious contexts, while a "suicide" is considered to be an offense made out of unknowning, confusion, or despair, assisted suicides are ostensibly actions made in faith, with no expectation of incurred sin or such that would bar transcendence to an afterlife. In certain religious denominations, particularly the Roman Catholic Church, suicides are considered a serious sin, and thus many Catholics oppose the practice of assisted suicide.

Legality


Assisted-suicide is legal in several jurisdictions, including Belgium, Luxembourg, the Netherlands, Switzerland and three American states (Oregon, Washington and Montana).

Australia
Assisted suicide is currently illegal in Australia, but was for a time legal in the Northern Territory under the Rights of the Terminally Ill Act 1995. In 1996, physician Philip Nitschke performed the world's first legal, voluntary euthanasia. Which is different than Physician- Assisted Suicide.

Belgium
In 2006, Belgium legalized partial euthanasia with certain regulations.
 * The patient must be an adult and in a “futile medical condition of constant and unbearable physical or mental suffering that cannot be alleviated”
 * Patient must have a long-term history with the doctors, resulting in euthanasia/physician assisted suicide only being allowed for people residing in the country
 * There need to be several requests that are reviewed by a commission and approved by two doctors.

A survey published in 2010 that those who died from euthanasia (compared with other deaths) were more often younger, male, cancer patients and more often died in their homes. In almost all cases, unbearable physical suffering were reported. Euthanasia for nonterminal patients was rare.

Canada
Suicide is not a crime in Canada, but physician-assisted suicide is considered illegal.

The Criminal Code of Canada states in section 241(b) that Every one who ….(b) aids or abets a person to commit suicide, whether suicide ensues or not, is guilty of an indictable offence and is liable to imprisonment for a term not exceeding fourteen years”

The reason behind its illegality is due to prevent people from ‘assisting in suicide’ of those that are not mentally capable of making the decision and because of the “value that society place on human life” which “in the eyes of the law makers, might easily be eroded if assistance in committing suicide were to be decriminalized.”

China
An article in People’s Daily reported that “Nine people from Xi’an City in China made news when they ‘jointly wrote to local media asking for euthanasia, or mercy killings’”. These people had uremia, a disease due to the failure of the kidneys, and expressed their “unbearable suffering and [an unwillingness] to burden their families any more” The article stated because it is illegal for doctors to help their patients die, all that could be done for them was to ask the doctors to ease their pain.

Colombia
Despite its strict Roman Catholic history, in May 1997 Colombian courts allowed for the euthanasia of sick patients who requested to end their lives. This ruling came about due to the efforts of a group that strongly opposed euthanasia. When one of their members brought a lawsuit to the Colombian Supreme Court against it, the court issued a 6 to 3 decision that “spelled out the rights of a terminally person to engage in voluntary euthanasia.”

Though physician assisted suicide is legal, the country has no way to document or set rules and regulations for doctors and patients that want to end their lives. Though it is opposed on religious grounds by many Colombians, many patients have still been able to find doctors to assist them in ending their lives.

France
The controversy over legalizing euthanasia and physician assisted suicide is not as big as in the United States because of the country's “well developed hospice care program”. However, in 2000 the controversy over the uncontroversial topic was ignited with Vincent Humbert. After a car crash that left him “unable to ‘walk, see, speak, smell or taste’”, he used the movement of his right thumb to write a book, I Ask the Right to Die (Je Vous Demande le Droit de Mourir) in which he voiced his desire to “die legally”. After his appeal was denied, his mother assisted in killing him by injecting him with an overdose of barbiturates that put him into a coma, killing him 2 days later. Though his mother was arrested for aiding in her son’s death and later acquitted, the case did jumpstart a new legislation which states that when medicine serves “no other purpose than the artificial support of life” they can be “suspended or not undertaken”.

Germany
Killing somebody in accordance with their demands is always illegal under the German criminal code (s. 216, "Killing at the request of the victim; mercy killing" ).

Assisting with suicide by, for example, providing poison or a weapon, is generally legal. Since suicide itself is legal, assistance or encouragement is not punishable by the usual legal mechanisms dealing with complicity and incitement (German criminal law follows the idea of “accessories of complicity” which states that “the motives of a person who incites another person to commit suicide, or who assists in its commission, are irrelevant” ). Nor is assisting with suicide explicitly outlawed by the criminal code. There can however be legal repercussions under certain conditions for a number of reasons. Aside from laws regulating firearms, the trade and handling of controlled substances and the like (e.g. when acquiring poison for the suicidal person), this concerns three points:

Free vs. manipulated will
If the suicidal person is not acting out of their own free will, then assistance is punishable by any of a number of homicide offences that the criminal code provides for, as having "acted through another person" (s. 25 par. 1 of the German criminal code, usually called "mittelbare Täterschaft"). Action out of free will is not ruled out by the decision to end one's life in itself; it can be assumed as long as a suicidal person “decides on his own fate up to the end […] and is in control of the situation.”

Free will cannot be assumed, however, if someone is manipulated or deceived. A classic textbook example for this, in German law, is the so-called Sirius case on which the Federal Court of Justice ruled in 1983: The accused had convinced an acquaintance that she would be re-incarnated into a better life if she killed herself. She unsuccessfully tried that, and the accused was eventually convicted of attempted murder. (He had also convinced her that he hailed from the star Sirius, hence the name of the case).

Apart from manipulation, the criminal code states three conditions under which a person is not acting under his own free will:


 * 1) if the person is under 14
 * 2) if the person has “one of the mental diseases listed in §20 of the German Criminal Code”
 * 3) a person that is acting under a state of emergency.

Under these circumstances, even if colloquially speaking one might say a person is acting of their own free will, a conviction of murder is possible.

Neglected duty to rescue
German criminal law obligates everybody to come to the rescue of others in an emergency, within certain limits (s. 323c of the German criminal code, "Omission to effect an easy rescue" ). This is also known as a duty to rescue in English. Under this rule, the party assisting in the suicide can be convicted if, in finding the suicidal person in a state of unconsciousness, they do not do everything in their power to revive them. In other words, if someone assists a person in committing suicide, leaves, but comes back and finds the person unconscious, he must try and revive him.

This reasoning is disputed by legal scholars, citing that a life-threatening condition that is part, so to speak, of a suicide underway, is not an emergency. Unfortunately (for those who would rely on that defence), the Federal Court of Justice has considered it an emergency in the past.

Homicide by omission
German law puts certain people in the position of a warrantor (Garantenstellung) for the well-being of another, e.g. parents, spouses, doctors,and police officers. Such people might find themselves legally bound to do what they can to prevent a suicide; if they do not, they are guilty of homicide by omission.

Japan
“Until recently, death and dying were considered taboo or inappropriate subjects for discussion in Japan.” Attitudes have changed primarily due to a recent case in which a doctor admitted to helping some of his cancer patients die by “switching or turning off their respirators”. Even though the Yokohama District Court established, in a 1995 ruling, guidelines under which a "mercy killing" (active euthanasia) would not be considered murder, it appears that the doctor in this case met some of the guidelines but not all.

According to the ruling, a mercy killing would not be considered a crime if:
 * “the patient was suffering from unbearable pain”
 * "the death of the individual was inevitable and imminent”
 * “All alternative measures have been taken to relieve the pain"
 * “the patient makes a clear statement of his or her desire to shorten his or her life or hasten death.”

The problem that arose from this, in addition to the problem faced by many other families in the country, has led to the creation of "bioethics SWAT teams". These teams will be made available to the families of terminally ill patients in order to help them, along with the doctors, come to a decision based on the personal facts of the case. Though in its early stages and relying on “subsidies from the Ministry of Health, Labor and Welfare” there are plans to create a nonprofit organization to “allow this effort to continue.”

Luxembourg
After failing to get royal assent for legalizing euthanasia, in December 2008 Luxembourg's parliament amended the country's constitution to take this power away from the monarch, the Grand Duke of Luxembourg. Euthanasia was legalized in the country in April, 2009.

The Netherlands
Physician-assisted suicide is legal under the same conditions as euthanasia.

New Zealand
Assisted suicide is illegal in New Zealand.

South Africa
As in the United States, South Africa is struggling with the debate over legalizing euthanasia. Due to the under-developed health care system that pervades the majority of the country, Willem Landman, “a member of the South African Law Commission, at a symposium on euthanasia at the World Congress of Family Doctors” stated that many South African doctors would be willing to perform acts of euthanasia when it became legalized in the country. He feels that because of the lack of doctors in the country, “[legalizing] euthanasia in South Africa would be premature and difficult to put into practice […]”

Switzerland
Though it is illegal to assist a patient in dying in some circumstances, there are others where there is no offence committed. The relevant provision of the Swiss Criminal Code refers to "a person who, for selfish reasons, incites someone to commit suicide or who assists that person in doing so will, if the suicide was carried out or attempted, be sentenced to a term of imprisonment (Zuchthaus) of up to 5 years or a term of imprisonment (Gefängnis)."

A person brought to court on a charge could presumably avoid conviction by proving that they were “motivated by the good intentions of bringing about a requested death for the purposes of relieving suffering” rather than for "selfish" reasons. In order to avoid conviction, the person has to prove that the deceased knew what he or she was doing, had capacity to make the decision, and had made an “earnest” request, meaning he/she asked for death several times. The person helping also has to avoid actually doing the act that leads to death, lest they be convicted under Article 114: Killing on request (Tötung auf Verlangen) - A person who, for decent reasons, especially compassion, kills a person on the basis of his or her serious and insistent request, will be sentenced to a term of imprisonment (Gefängnis). For instance, it should be the suicide subject who actually presses the syringe or takes the pill, after the helper had prepared the setup. This way the country can criminalise certain controversial acts, which many of its people would oppose, while legalising a narrow range of assistive acts for some of those seeking help to end their lives.

The status of healthy individuals seeking to end their own lives remains unresolved under Swiss law. As of 2009, Dignitas was pursuing the case of a Canadian couple, Betty and George Coumbias, who wished to end their lives simultaneously.

In July 2009, British conductor Sir Edward Downes and his wife Joan died together at a suicide clinic outside Zürich "under  circumstances of their own choosing". Sir Edward was not terminally ill, but his wife was diagnosed with rapidly developing cancer.

In March 2010, the PBS FRONTLINE TV program in the United States showed a documentary called "The Suicide Tourist" which told the story of Professor Craig Ewert, his family, and Dignitas, and their decision to commit assisted suicide using Sodium Pentobarbital in Switzerland after he was diagnosed and suffering with ALS (Lou Gehrig's Disease).

United Kingdom
Two previous attempts to legalize assisted suicide have been rejected by the UK Parliament. In the meantime the Director of Public Prosecution has clarified the criteria under which an individal will be prosecuted for assisting in another person's suicide. A bill is currently before the Scottish Parliament to permit Assisted Suicide. The Catholic Church is fiercely opposed to the bill however the other main Scottish religious body, the Church of Scotland, is deeply split over the issue. The Kirk's central committees in Edinburgh have submitted a report detailing their opposition but this has been countered by strong support and written submissions from the sections of the parish clergy led by the Rev Dr John Cameron and others.

United States
Assisted suicide is legal in the three American states of Oregon (via the Oregon Death with Dignity Act ), Washington (by Washington Death with Dignity Act), and Montana (through a trial court ruling). There are relatively substantial barriers to the use of some of these provisions.

For instance, Oregon requires a physician to prescribe medication but it must be self-administered. The prognosis must be for a life span of 6 months or less. The person must be a 'resident' of Oregon. A written request for prescription and two oral requests from the patient are also needed to escape criminal liability, plus written confirmation by doctor that the act is voluntary and informed. This limited model has withstood Constitutional scrutiny: Gonzales v Oregon 368 F. 3d 1118 (2004), affirmed by 546 U.S. 243 (2006)

Organizations in support of assisted suicide
Listed below are some major organizations that have been formed in support of assisted suicide:

Exit
Also known for a time as The Voluntary Euthanasia Society of Scotland is a leading source of self-deliverance information worldwide. It published the first self-deliverance (rational suicide) booklet in the world in 1980, How to Die With Dignity, after breaking with its parent organisation that was formed in 1935 (Then known as Exit but now, Dying With Dignity). In 1993, published Departing Drugs, which was translated into several languages worldwide; and in 2007 published Five Last Acts, a comprehensive book on self-deliverance. Website: www.euthanasia.cc

Exit International
An Australia-based group headed by Dr Philip Nitschke.

Euthanasia Research & Guidance Organization (ERGO)
ERGO’s mission is to provide information and literature on the right to choose to die by a competent adult, either by assisted suicide or self-deliverance. ERGO, incorporated under Oregon law in 1993 as a nonprofit educational organization, has more than 5,000 supporters (2009). ERGO maintains three web sites www.finalexit.org, www.assistedsuicide.org and www.assistedsuicide.org/blog and delivers an internet news digest focusing on right to die issues to subscribers around the world. ERGO's Bookstore distributes ‘Final Exit’, the well-known ‘how-to’ book by Derek Humphry and contributes the profits to other right to die groups. Since 1999, ERGO has hosted the suicide device research group NuTech which meets in various world cities to examine new ways of legal self-deliverance.

Death with Dignity National Center
The Death with Dignity National Center is a nonprofit organization that has been in existence since 1993. This organization is most notably associated with the original writing and continued advocating of the Oregon Death with Dignity Law that was enacted on October 27, 1997. This law has become the landmark to changing laws everywhere in association with end of life care of terminally ill patients. The Death with Dignity Center’s ultimate goal is to use the Oregon law as a model for other states with the hopes that there will one day be improved health care and treatment options for all terminally ill patients.

Compassion & Choices
Compassion & Choices is a non-profit organization that supports, advocates, and educates people about health care options that can expand choice at the end of life. The organization was formed via the merging of Compassion in Dying and End-of-Life Choices organization (formerly known as the Hemlock Society). This organization seeks to educate the public and foster compassion so as to understand why many people who experience needlessly unrelenting pain may wish to end their pain and lives prematurely. Compassion and Choices has been essential in aiding the legislative process in trying to pass laws to help give terminally ill and mentally-able patients a choice in their end of life options. On November 4, 2008, the organization saw the results of their hard work come to fruition when Washington became the second state to legalize aid in dying. Voter support for the legalization was an overwhelmingly 59% for to 41% against.

World Federation of Right to Die Societies
The World Federation of Right to Die Societies was founded in 1980 and encompasses thirty-eight right to die organizations in twenty-three different countries. The federation serves as an international link between organizations whose aim is to provide people with self-determination and dignity during death. The board of directors of this alliance supports legal changes that will allow people who suffer from incurable diseases to obtain humane death in a dignified way.

Final Exit Network
Final Exit Network is a non-profit organization that is run by volunteers. It is one of the newer organizations in support of assisted suicide as it has only been in operation for the past four years. The group has four main goals which center on promoting the use of advanced directives and stepping in when the wishes of the patient are not being honored. It is the belief of this association that people with irreversible conditions that cause them suffering in ways they can no longer tolerate should be given peaceful and reliable ways to end their lives if they choose. This network does not seek legislative changes as they do not believe that these changes will come fast enough. Instead they have their own operations set up to assist people with a peaceful and painless death. They accept people whom other organizations may turn away. Some examples of the types of people they accept include but are not limited to: people with cancer, Parkinson's disease, and congestive heart failure.

Dying with Dignity
Dying with Dignity is a non-profit Canadian organization that was founded in 1980. It is concerned with the treatment of terminally ill patients and is aiming to improve the quality of those dying. They advocate for improved hospice services and painless health care services that will provide a peaceful death to terminally ill patients. They are in favor of legislative changes that will allow people to have end of life options that will include assisted suicide if it is what they so desire.

Dignity in Dying
Dignity in Dying is a voluntary organization located in London. This group believes that terminally ill patients deserve access to information that provides them with a choice on where to die and who should be present. They fight for change by lobbying to law makers in hopes of improving laws that govern patient choice. They also hope to promote change by educating people who work in the medical and legal professions about end-of-life decisions. This group is trying to get a debate going in Parliament after they were able to get one-hundred of them to sign an EDM (Early Day Motion). This motion is aimed at repealing the Suicide Act of 1961 which prohibits assisted suicide. The Dignity with Dying organization argues that this Act causes people to go abroad to get help with assisted suicide, turn to love ones for assistance in suicide, or receive the treatment illegally. It is the hope of this association that parliament will overturn the Suicide Act of 1961 that allow patients suffering from incurable diseases to seek painless end-of-life treatment to end their lives.

Dying with Dignity Victoria
Dying with Dignity Victoria (formally known as the Voluntary Euthanasia Society of Victoria Inc.) was founded in 1974. This organization involves itself in educating people about the issue via self help resources. The organization also pursues public policy and seeks to implement legislative changes that aim to provide dignity for patients at the end of their lives. The association's activities have helped bring about the Medical Treatments ACT (1985) which legalized the right of patients to refuse medical treatment. The group lobbies to ensure that the laws already established regarding end-of-life rights do not get eliminated.

Dignity New Zealand
This organization was founded in August 2003 under the name Exit DZ as a direct result of Parliament’s decision to deny the death with dying bill. It was in May 2005 that Exit DZ was renamed Dignity DZ. It is the belief of this organization that terminally ill patients should have the option of assisted suicide and should not be given consequences if opting to do so. The parliament of New Zealand has rejected two pieces of legislation regarding the use of assisted suicide for terminally ill patients. Although both of these attempts were upsetting for the Dignity DZ organization they are continuing with their agenda to make assisted suicide for terminally ill patients a viable choice. The members of this organization understand that freedom of choice is essential for complete human identity and realize that free choices should also be incorporated with death and dying decisions.

Published research
{This section summarises research published in peer-reviewed journals}

A study approved by the Dutch Ministry of Health, the Dutch Ministry of Justice, and the Royal Dutch Medical Association reviewed the efficacy in 111 cases of physician-aided dying (PAD). This showed that 32% of cases had complications. These included 12% with time to death longer than expected (45 min – 14 days), 9% with problems administering the required drugs, 9% with a physical symptom (e.g. nausea, vomiting, myoclonus) and 2% waking from coma. In 18% of cases the doctors had to provide euthanasia because of problems or failures with PAD.

The Portland (Oregon) Veterans Affairs Medical Center and the Department of Psychiatry at the Oregon Health and Science University set out to assess the prevalence of depression in 58 patients who had chosen PAD. Of 15 patients who went to receive PAD, three (20%) had a clinical depression. All patients who participated in the study were determined in advance to be mentally competent. The authors conclude that the "...current practice of the (Oregon) Death with Dignity Act may fail to protect some patients whose choices are influenced by depression from receiving a prescription for a lethal drug".

In a Dutch study of patients with severe and persistent symptoms requiring sedation, the researchers found that only 9% of patients received a palliative care consultation prior to being sedated.

Attitude of Health care professionals
A 1997 anonymous mail study directed by David A. Asch MD, MBA and Michael L. DeKay, Ph.D, sent out surveys to 1,560 United States critical care nurses, only 73% responded, about their feelings involving physician assisted suicide. The survey investigated the reasons why some critical care nurses were denouncers of the practice, while others were supporters of it. One obvious explanation for why some nurses have sympathetic tendencies towards euthanasia is because, "some...see euthanasia as a legitimate response to end human suffering". However, Asch and DeKay cited additional factors that influence health  care professionals' attitudes towards euthanasia including religion, religiosity, and age.

In the UK, an extensive survey of 3733 medical physicians in 2009 was sponsored by the National Council for Palliaitve Care, Age Concern, Help the Hospices, Macmillan Cancer Support, the Motor Neurone Disease Association, the MS Society and Sue Ryder Care. It showed that the proportion against a change in the law was 66% against euthanasia and 65% against assisted dying. Opposition to euthanasia and PAS highest amongst Palliative Care and Care of the Elderly specialists, while more than 90% of palliative care specialists are against a change in the law.

In another UK study, by Glasgow University's Institute of Law & Ethics in Medicine, a postal survey of UK medical practitioners and pharmacists, 54% were in favour of a change in the law to allow physician-assisted suicide to take place in specific circumstances, with only 36% against. 60% of the 1000 practitioners who responded had treated a patient who was considering suicide, 12% personally knew another health professional who had assisted a patient to kill themselves and 4% had themselves provided the means (such as drugs or information about lethal acts) to assist a patient to kill themselves. One interesting finding of the second study was that most medical practitioners found physician-assisted suicide preferable to voluntary euthanasia (43% in comparison to 19%), especially in view of the findings of a first study by the University which showed the public's preference for voluntary euthanasia. There was little by way of differences in the percentages of hospital physicians, medical GPs, surgeons or psychiatrists favouring a change in the law - approximately 48% were in favour. This was in stark contrast to the percentage of pharmacists in favour (72%) and anaesthetists (56%). Pharmacists were twice as likely as medical GPs to endorse the view that "if a patient has decided to end their own life then doctors should be allowed in law to assist". (McLean, S., 1997, "Sometimes a Small Victory", Institute of Law and Ethics in Medicine, University of Glasgow.)

Evidence shows that assisted dying is rare in the UK. In a survey of 8857 physicians, the proportion of UK deaths involving voluntary euthanasia (0.21%; CI: 0–0.52), physician-assisted dying (0.00%) and ending of life without an explicit request from the patient (0.30%; CI: 0–0.60) was very low.

Factors that influence physicians' attitudes towards physician assisted death
Religion, religiosity, age, gender, previous experience with physician assisted suicide, and work environment are all factors which influence health professionals' attitudes towards physician assisted death.


 * The study found that nurses who had previously been a participant in physician assisted death were; "younger, less religious, and more likely to be male".
 * A second study conducted in Australia, on end of life treatment reported results that those who are the most likely to oppose physician assisted death are older, western educated, catholic and female.
 * Physicians who identify themselves as palliative care professionals are less willing to support the practice of physician assisted death.
 * Of the nurses included into the study 19% reported previous participation in physician assisted death, 76% reported never having engaged in physician assisted death and 4% of respondents were unclassifiable.
 * Those who have previous engagement in euthanasia were more likely to respond to the survey that they felt that passive and active euthanasia are ethical practices.
 * Age is an important variable in predicting the attitudes of a health care professional towards euthanasia, "for every additional year of age the odds of having engaged in euthanasia decrease by 3.1%"
 * The variable of age does not tell us whether age is the only factor in changing attitudes towards physician assisted death or if the younger nurses simply reflect changes in attitudes towards physician assisted death over time.

Opposition
There are many health care professionals, especially those concerned with bioethics, who are opposed to PAD due to the detrimental effects that the procedure can have with regard to vulnerable populations. This argument is known as the "slippery slope" argument. This argument encompasses the apprehension that once PAD is initiated for the terminally ill it will progress to other vulnerable communities and may begin to be used by those who feel less worthy based on their demographic or socioeconomic status. In addition, vulnerable populations are more at risk of untimely deaths because, "patients might be subjected to PAD without their genuine consent". However, recent studies show that the available evidence suggests that the legalisation of physician-assisted suicide might actually decrease the prevalence of involuntary euthanasia.
 * "Slippery slope" argument

Also, prejudices against disabled people may be enacted with regards to end of life care. For example, do not resuscitate orders are more frequently issued for those who become hospitalized and previously suffer from severe disabilities. In addition, many people who suffer from lifelong disabilities suffer from "burn out", which is a general feeling of depression and sadness that comes as a result of years of intolerance and prejudice. Naturally, those individuals suffering from "burn out" are more likely to want to refuse treatment and end their fight for life prematurely.
 * Prejudices against the disabled

Improvements in end of life decision making
Currently only a small fraction of patients, about 15% have clear directions in the form of a living will or a health care proxy in place to advise family members or physicians of their end of life wishes. This leads to uncomfortable questions if the patient suddenly no longer has the ability to speak for themselves when answers are needed to important medical questions. Even if a patient has selected a proxy they may, "be guilt ridden, wondering whether they acted to hastily or if their decision was inconsistent with the patient's desires"

In order to preempt some of the difficulties that are associated with end of life care many medical schools and nursing programs now stress the importance of early discussions with the patient about their wishes and planning for the future. Unfortunately, since the views concerning physician assisted suicide are so polarizing, many doctors are reluctant to discuss withholding and withdrawing life sustaining treatment. In fact, in a recent study of 58 physicians, 19 admitted that they did not feel comfortable discussing end of life care with their patients.

In an effort to change the apprehension that is associated with end of life care new techniques are being explored to ensure more doctor to patient communication including:
 * analyzing the cognitive ability of the patient to make their own decision regarding end of life care
 * encouraging doctors to initiate end of life conversations
 * making sure that the patient is made fully aware of all options regarding their personal medical treatment
 * providing counseling and support for families of patients especially in situations where a decision to remove life support and/or stop treatment is involved

In short there are two major ways in which the physicians can more easily be made aware of the wishes of their patients. The first of which simply involves participation in the informed consent process or, "engaging competent patients in comprehensive discussions of treatment options and likely outcomes". The second of these methods involves advance care planning which ensures that patients tell their doctors exactly what they wish to be done in case a medical emergency arises in which they are not able to speak for themselves.