Abstract
BackgroundEnd-of-life decisions remain controversial. Switzerland, with three main languages shared with surrounding countries and legal suicide assistance, allows exploration of the effects of cultural differences on end-of-life practices within the same legal framework.MethodsWe conducted a death certificate study on a nationwide continuous random sample of Swiss residents. Using an internationally standardized tool, we sent 4998, 2965, and 1000 anonymous questionnaires to certifying physicians in the German-, French-, and Italian-speaking regions.ResultsThe response rates were 63.5%, 51.9%, and 61.7% in the German-, French-, and Italian-speaking regions, respectively. Non-sudden, expected deaths were preceded by medical end-of-life decisions (MELDs) more frequently in the German- than in the French- or Italian-speaking region (82.3% vs. 75.0% and 74.0%, respectively), mainly due to forgoing life-prolonging treatment (70.0%, 59.8%, 57.4%). Prevalence of assisted suicide was similar in the German- and French-speaking regions (1.6%, 1.2%), with no cases reported in the Italian-speaking region. Patient involvement was smaller in the Italian- than in the French- and German-speaking regions (16.0%, 31.2%, 35.6%). Continuous deep sedation was more frequent in the Italian- than in the French- and German-speaking regions (34.4%, 26.9%, 24.5%), and was combined with MELDs in most cases.ConclusionWe found differences in MELD prevalence similar to those found between European countries. On an international level, MELDs are comparably frequent in all regions of Switzerland, in line with the greater role given to patient autonomy. Our findings show how cultural contexts and legislation can interact in shaping the prevalence of MELDs.
Highlights
Focusing on the most explicit practice, forgoing life-prolonging treatment was the most frequent medical end-of-life decisions (MELDs) in the Germanspeaking region and intensified alleviation of symptoms the most frequent in the French-speaking region (49.3% of non-sudden expected deaths and 39.8%, respectively), with both being frequent in the Italian-speaking region (34.8% and 37.4%, respectively)
Assisted suicide was reported in 1.6% and 1.2% of non-sudden expected deaths in the German- and French-speaking regions, with no cases reported in the Italian-speaking region in our sample
This is in line with other studies suggesting that Switzerland is among the European countries where patient autonomy is given a greater weight in MELDs [20, 21]
Summary
Switzerland, with three main languages shared with surrounding countries and legal suicide assistance, allows exploration of the effects of cultural differences on end-of-life practices within the same legal framework. Debates regarding the legal status of such decisions assume that legislative differences [1] and care settings [2, 3] largely determine international variation in prevalence. Countries where these decisions are legal and where several cultures co-exist, such as Switzerland, Belgium, the US, and more recently Canada, present an important opportunity to explore the role of legal and cultural frameworks for variations of end-oflife decisions. “Suicide tourism” toward Switzerland has influenced end-of-life debates in countries such as Germany, the UK, the US, and Canada, from which many assisted suicide candidates originate [9]
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