"Palliative care does not aim to delay or hasten death but rather to facilitate the transition from life to death while enhancing the quality of life." (Lorenz, 2008 in Sener & Dikmen, 2023)
Palliative care is not merely "end-of-life" or "brink-of-death" care. The latest challenge is to provide effective support for those living with cancer or other terminal illnesses over extended periods. They often experience a complex combination of the impacts of the disease itself, treatment effects, and psychosocial and psychospiritual consequences. In addition to facing fears of recurrence, deterioration, or death, they are also confronted with persistent symptoms such as fatigue, disability, and changes in social and family roles and dynamics (Kitchen et al., 2024).
Euthanasia and physician-assisted suicide are two topics that have been discussed throughout history, primarily because both relate to the right to life as a human right that has been universally upheld for many years. However, the meaning of euthanasia, which translates to "a good death," creates conflicts at social, moral, and ethical levels (Marin, 2018).
Euthanasia in Palliative Care
According to Lorenz (2008) in Sener & Dikmen (2023), in palliative care, death is viewed as a natural process, and access to palliative care is considered a human right. Palliative care does not aim to delay or hasten death but rather to facilitate the transition from life to death and enhance quality of life. There are two main perspectives related to euthanasia and physician-assisted suicide. The first perspective asserts that quality palliative care cannot coexist with euthanasia and physician-assisted suicide. Patients' requests for euthanasia are often driven by issues such as lack of access to palliative care and inadequate outcomes in alleviating their pain and suffering. In contrast, the second perspective argues that palliative care can provide effective support to patients in making decisions about euthanasia and physician-assisted suicide, as well as improving understanding of end-of-life care options (Huemer et al., 2021).
From these viewpoints, it can be concluded that palliative care plays a crucial role in supporting patients with terminal illnesses, focusing on enhancing quality of life and facilitating a natural transition toward death. Despite the differing perspectives on the relationship between euthanasia and palliative care, both highlight the importance of adequate access to palliative care. Palliative care should be prioritized to alleviate patient suffering and provide them with meaningful choices at the end of their lives.
Research by Zenz et al. (2015) reveals a striking difference in attitudes between doctors and nurses in end-of-life care practices such as euthanasia and physician-assisted suicide. Doctors tend to be more willing to engage in such actions compared to nurses, whether in terminal or non-terminal cases. The research shows that while nurses support euthanasia, they are more hesitant to become directly involved in its implementation. The ambiguity of the nurse's role in end-of-life care practices contributes to their uncertainty. In Belgium, the law requires doctors to discuss euthanasia requests with the nursing team, emphasizing their important role in the process. Nurses often become the ones who receive expressions of patients' wishes regarding the end of life. Although involved in euthanasia decision-making, many nurses in the Netherlands are unwilling to administer fatal doses or participate in euthanasia review teams. Nurses tend to be cautious and hesitant to directly engage in such actions. This reflects the ethical and legal complexities surrounding the practice of euthanasia in various countries.
The importance of Early Palliative Care also supports the prevention of euthanasia requests among patients. A study conducted by Bandieri et al. (2024) highlights the significance of Early Palliative Care in addressing not only physical pain but also spiritual and psychological needs, providing safety and hope to patients and their caregivers.
Viewing Euthanasia from Ethical Principles
The American Medical Association asserts that euthanasia and physician-assisted suicide are inherently at odds with the physician's role as a healer, challenging or even impossible to manage, and can present significant risks to society. Similarly, the World Medical Association states that euthanasia, which entails deliberately terminating a patient's life---even if requested by the patient or their close relatives---is considered unethical. Nevertheless, this does not inhibit physicians from honoring patients' wishes to permit the natural dying process to take place during the final stages of illness (De Lima et al., 2017).
The physician's oath worldwide is based on the Geneva Declaration, which states, "I will maintain the utmost respect for human life from the moment of conception, and even under threat, I will not use my medical knowledge contrary to humanitarian law." Based on the physician's oath and the opinions of experts, it can be concluded that doctors and other healthcare professionals are not permitted to perform euthanasia. Instead, they are required to use all their skills and expertise to alleviate suffering, preserve life, and not to end a person's life. To date, actions that cause someone's death have not been legally accepted. In line with this, the Declaratio de Euthanasia from SC Pro Doctrine Fidei on May 5, 1980, states, "No one may request a lethal action for themselves or for others who are under their responsibility" (Flora, 2022).
Euthanasia, from the nursing perspective, also does not reflect the principles of nursing ethics. The application of ethical principles is one of the 12 competencies that a nurse must possess according to the standards set by the Indonesian Nursing Association (PPNI). Nurses must always adhere to the principles of nursing ethics, such as autonomy (patient independence), non-maleficence (do no harm), beneficence (doing good), justice (fairness), veracity (truthfulness), and fidelity (keeping promises) (Fadillah & Jannah, 2017).
The legalization of euthanasia in several countries creates challenges for nurses in facing a series of complex ethical and moral decisions, as it relates to the extent to which one is involved in these new care choices (Pesut et al., 2020). Nurses have diverse perceptions of euthanasia, often influenced by their ethical values, religion, and professional experiences. Some nurses view euthanasia as a violation of the principle of care that focuses on preserving life, while others accept this practice as an option to end patients' inevitable suffering. Ultimately, nurses' perceptions of euthanasia are influenced by the legal and cultural frameworks in which they work (Cayetano-Penman et al., 2020). Similarly, research by Cordeiro et al. (2022) indicates that nurses reject euthanasia because it contradicts professional ethics and moral values, while others support it as a means to alleviate the suffering of terminal patients. Factors such as family support, colleagues, and bioethical principles, including beneficence and autonomy, influence their decisions.
Global Trends Regarding Euthanasia
The pain suffered by patients is not the primary reason for requesting euthanasia. Factors that more often drive requests for euthanasia include the loss of autonomy, decline in quality of life, and loss of dignity, which underlie 61% of cases in the Netherlands and 52% in Belgium (Mroz et al., 2021).
Patients and physicians frequently have misconceptions regarding the distinctions between palliative care and euthanasia. A study by Leboul et al. (2022) revealed that many patients seeking euthanasia in palliative care settings often fail to grasp or overlook the differences between the two. Such requests typically stem from patients seeking medical help to end their lives, rather than a simple wish to hasten death or an aimless desire to die. This misunderstanding can be attributed to various factors, including the occurrence of rapid deaths within palliative care units, the administration of morphine and sedatives, and legal frameworks that acknowledge the right to relief from intolerable suffering, which often require palliative care teams to be involved in decision-making processes after patients express their wishes.
Research by Chutarattanakul et al. (2024) shows a high prevalence of misunderstanding between palliative care and euthanasia among doctors in Thailand. Many doctors mistakenly assume that discontinuing life-sustaining procedures at the patient's request and allowing palliative patients to die in hospitals constitute euthanasia. Additionally, some doctors confuse the belief that using sedatives and muscle relaxants to hasten a patient's death is part of palliative care, while using them to relieve suffering is considered euthanasia.
Both studies indicate that limited knowledge and confusion regarding the concepts of palliative care and euthanasia occur not only among patients but also among doctors. This highlights the importance of better education and training to ensure a clear understanding of the concepts of palliative care and euthanasia, enabling patients to make informed decisions about their end-of-life care and allowing doctors to provide accurate information and avoid errors in care.
From various studies, it can be concluded that palliative care does not only focus on end-of-life treatment but also aims to improve patients' quality of life. Better education and training regarding the concepts of palliative care and euthanasia are crucial to ensuring clear understanding. This can assist patients in making informed decisions about their end-of-life care, as well as helping doctors provide accurate information and avoid care errors. Overall, palliative care plays a vital role in supporting patients facing terminal illnesses; however, misunderstandings about euthanasia and the need for improved education to ensure a clear understanding of the concepts of palliative care and euthanasia remain critical.
It is important to provide broader access to quality palliative care, which not only alleviates physical suffering but also meets the psychosocial and spiritual needs of patients. Adequate access to this care can reduce requests for euthanasia, as patients will feel more holistically supported in facing the end of their lives.
Palliative care plays an essential role in supporting patients with terminal illnesses, focusing on improving quality of life and not merely addressing end-of-life issues. The new challenges faced include long-term support for patients living with cancer or other diseases. Euthanasia and physician-assisted suicide are topics that provoke ethical, social, and moral debates, especially regarding the right to life. Although there are differing views on the relationship between euthanasia and palliative care, both highlight the importance of adequate access to palliative care to alleviate suffering and provide meaningful choices for patients.
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