“We need to talk!” Barriers to GPs’ communication about the option of physician-assisted suicide and their ethical implications: results from a qualitative study

A purposive sampling of 30 GPs was chosen from the FMH (Swiss Medical Association) list in order to obtain the maximum variety in terms of practice size (group vs. single), location (practices in different cantons and in urban, rural or suburban regions), and doctors’ gender and age. Selected GPs were contacted via an e-mail outlining the research. Semi-structured face-to-face interviews, approximately 1 h in length, were conducted with the participants. These participants were based in the French, Italian, and German speaking areas of Switzerland. The interviews took place between December 2012 and February 2013. The interviews were conducted by IO and CJ (both authors of this paper). Both interviewers (IO and CJ) are sociologists specializing in qualitative research methods and interviewing techniques. An interview guide was used for all interviews, which evolved as new insights were gained during the data gathering process and led to a more in-depth exploration of this topic. Among the question sets concerning administering palliative care and their networking with other institutions and stakeholders, the participating GPs were asked about their reactions to and handling of requests for assisted suicide. The study was approved by the competent ethics committee (Ethics Committee northwest/central Switzerland “EKNZ”) in November 2012 and all participants provided informed consent.

The interviews were transcribed verbatim (using the transcription software “F4”). IO and CJ carried out an independent analysis of all transcripts (using Atlas.ti). Additionally, a secondary coding was performed by KB and BE. Critical reviews of each analysis of each interview were performed in order to help us to become aware of our own backgrounds and potential bias (reflexivity) (Malterud 2001; Malterud 2002). The codings were then reviewed by two independent researchers to ensure inter-rater reliability.

The coders followed Mayring’s steps of content analysis (Mayring 2003; Lamnek 2010). In a first step, the data was coded separately by IO and CJ, moving from concrete passages to more abstract levels of coding including emerging themes. Both coders then discussed their codes and re-coded the data again. After five interviews a preliminary coding guide was developed which was adapted continuously throughout the analysis, adding new codes emerging from the material, if necessary. In team meetings all findings were critically tested and discussed by all coders. Any disagreements were solved by discussion. Since the coding system remained the same for the final interviews and no new codes/themes emerged, we concluded that we had reached saturation.

GPs who stated that they avoid talking about PAS requests emphasized their uncertainty about their ability to cope emotionally with assisting a patient in ending their life. They stated that they fear their own psychological health might be at risk. Instead of PAS, they try to find a way to support the patient without intentionally causing death, for example by giving the patient morphine. Especially in cases where they have a long and well developed patient–physician relationship, the emotional impact of PAS requests increases due to their personal connection to the patient. While they could empathize with terminally ill patients’ wishes to die, the feeling of not being able to handle the emotional, ethical, or psychological impact was overwhelming for them. A few physicians reported that they always felt relieved when they did not have to talk about a request for PAS.

GP4: I do not feel competent to deal with the topic of assisted suicide, and I do not want to either. Especially for my personal psychological health, when I know the patient for a while. I find this legitimate, and I am always relieved when I do not need to think about this topic.

GP19: One of the things I try to tell them is that I cannot bear the idea of killing one of my patients. I’m not strong enough for that, I cannot cope with it.

GP23: When someone asks for help, I explain that I do not do assisted suicide. It’s me, I cannot do it, I feel like I would not be capable—psychologically. So I admit I would never do it. I would give them morphine or something like that.

GP5: To me, it is important to clarify the situation as early as possible. I tell them that I could never do it. I say that at the very beginning. This way I can avoid discussing this topic. I guess one consequence of my behaviour is that I choose the easiest patients to treat.

Some of the interviewed GPs who did not want to assist a suicide commented that their opinions are related to their personal values. However, all of them acknowledged that situations may arise in which a request for PAS is quite understandable. While these GPs acknowledge and respect the wishes of their patients, they stated that their own “set of moral values” was the reason for their refusal to assist their patients in ending their lives. They feel committed to relieving a patient’s suffering and most agree that physician assisted suicide might, in some cases, be an option for patients. However, they do not want to take an active role in PAS. They would rather search for other options for their patients, such as improved palliative care, the transferal to another doctor or psychological support. As shown in the following quote, the refusal to assist a patient in dying can also lead to a postponement of the conversation about this option to a later moment “when the time has come”.

GP17: Some patients requested it, but I told them: “No, do not rely on me to give you the prescription of this product, no”. I tell them clearly: “do not count on me, it (PAS) is against my beliefs, but I respect your choice, and I’m ready to help you and to accompany you otherwise. We also do not have to talk about this topic now, we will see when the time has come”.

However, as shown in the following quotes, though most participants acknowledge that situations may arise in which a request for PAS is understandable, they still cannot participate in this procedure due to their personal values and beliefs:

GP18: I can totally understand why an assisted suicide can be meaningful. I just cannot support it. It simply challenges my beliefs.

Some of them also think that there are other, sufficient options such as palliative care or psychological support: GP13: I had to tell that patient that I am sorry, but that it is not compatible with my own philosophy and that there are other sufficient options such as palliative care or psychological support.

Several GPs contend that PAS is not a part of their professional role. They believe their duties are to ensure the patients’ quality of life, to alleviate pain and suffering, and to provide support to patients and their families. They also fear that their involvement with PAS could lead to confusion about their roles as doctors or could make assisted suicide look like a “normal medical procedure”. Some of them underlined that patients’ wishes for an assisted suicide were a psychological issue and possibly avoidable. As soon as the patients received treatment, either from a psychiatrist for their psychological suffering or from a GP who is able to relieve their physical pain, the wish for an assisted suicide, in their opinion, vanishes.

GP23: Me, I listen, listen to my patients, but I cannot give them the medication, I cannot see myself doing it. I think it’s not my role. Another aspect is…, it seems clear to me, that we cannot declare assisted suicide as a normal medical procedure, because otherwise the pressure of our society on aged people might grow to that extent that those people in retirement homes might get the feeling that it is their duty to commit assisted suicide, because they only cost money or because they are “useless”.

GP20: It’s quite unusual but when it happens it often demonstrates that they (the patients) feel weakened, they are now in a situation where they feel worse. If you manage to read behind the suffering and if you manage to answer to this pain most people forget they talked about suicide because they have their answer.

GP15: I don’t talk about it because it is not part of my job, the person needs care I cannot give in my cabinet. Generally, I try to convince the person to see a psychiatrist.

GP12: I think if I was promoting suicide, a lot more of my patients would do so. We are really underestimating the influence we have as doctors, especially during end of life care, where people need to give up more responsibilities about themselves. So for me, assisted suicide can never be a part of my professional role.

GPs who addressed this theme based their rejection mainly on their feeling of not being able to handle the emotional impact of PAS. In order to better understand their feelings, it might be important to acknowledge that although it is legally possible, the handling of requests and the procedure of PAS is still relatively new to GPs. Before 2004, professional guidelines in Switzerland had considered PAS to be incompatible with the aims of medical practice (SAMS 1995). Thereafter, the guidelines of the Swiss Academy of Medical Sciences regarding PAS were broadened (SAMS 2004). This rather recent and still controversial change may therefore leave GPs feeling insecure about the process of PAS, its legal prerequisites and how to proceed professionally.

As a step towards overcoming this barrier, other studies have shown that further education and training can have positive effects on GPs and their capability to deal with the potential psychological impact of PAS (Gastmans et al. 2004; Gamondi et al. 2013a). Therefore, the topic of PAS and its possible effects on medical professionals should be included in the official vocational training program for general practice. Currently, postgraduate training in Switzerland seldom covers the subject of PAS (Eychmüller et al. 2015). Additional knowledge concerning PAS and its legal and ethical prerequisites could help to limit the feeling of discomfort expressed by GPs.

Concerning GPs’ concerns about the expected psychological impact, van Marwijk et al. (2007) have shown that ensuring that sufficient time is available for all involved parties to deal with the emotional component of PAS could be another way to reduce potential discomfort. Other studies have shown that team consultations and guided group supervisions of all medical professionals involved, paired with a strengthened education, can help GPs to handle the emotional and psychological impact (Berghe et al. 2013). Berghe et al. (2013) further report that medical professionals who formerly declined patients’ requests for similar reasons found it helpful to accompany a patient undergoing the procedure as a witness, learning that the patient was relieved to gain back control and grateful that his “final days did not have to last any longer”, whether or not all medical possibilities had been exhausted. As a result, these medical professionals were convinced that the procedure could be part of “genuinely good care” which then minimized their discomfort (Berghe et al. 2013).

Interviewees in this group found PAS to be in direct conflict with their own morals and values. They base their refusal to communicate with their patients about PAS on personal ethics. They are not against PAS in the context of their profession, but because of their individual opinions. The GPs in our study were aware of their personal struggle with this topic and acknowledged that medical professionalism requires them to be aware that their own personal values might have an impact on offered treatment choices and therefore on patient autonomy.

One possible impact on patient autonomy was apparent when GPs reported their attempt to postpone final decisions with their patients by offering to accompany them and to talk about PAS “when the time has come”. However, by encouraging the postponing of a final decision, GPs risk compromising patients’ autonomy since patients need to fulfil certain criteria for PAS, such as displaying competence and the ability to take the PAS medication by themselves (Guillod and Schmidt 2005). Rather than postponing the decision, a better option to ensure patient autonomy could be the transfer of the patient to a colleague or a right-to-die organisation once a patient’s concrete decision to proceed with assisted suicide has been made. However, in terms of continuity of care, the option of referring a patient to a different colleague or organisation should be thoroughly planned and well considered, since the patient will then be treated outside his or her familiar care environment, which might not be optimal (Berghe et al. 2013).

Nevertheless, it is also important to note that despite all the support that can be offered (e.g. better education on the subject, group consultations, guided team supervision, accompanying of a patient undergoing PAS as a witness etc.), it must be understood that no-one can be compelled to participate in any form of suicide assistance if it is incompatible with their own moral stance or endangers their psychological health (Ersek 2004). This dilemma requires a personal decision of conscience and as such must be respected as long as it does not prevent a GP from offering other options to the patient (e.g. a transfer to a different GP) in order to ensure full patient autonomy.

Some interviewees stated that their main reason to reject a conversation about PAS is because they see conflicts with their professional role when being asked for their assistance. Their understanding of the medical ethos, with the aim of healing patients while trying to avoid causing additional harm, may contribute to their way of handling PAS requests. However, some of the GPs acknowledged that there are additional medical goals that physicians have to take into account, e.g. the respecting of patients’ personal values and priorities. The Swiss Academy of Medical Sciences has also identified this dilemma. According to their guidelines, PAS cannot be part of a doctor’s role because it contradicts the aims of medicine (SAMS 2004). In paragraph 4.1 they state that the proper task of doctors is to relieve patients’ suffering, not to offer them assistance in committing suicide (SAMS 2004). However, one could argue that refusing to relieve a patient’s suffering by providing PAS amounts to causing harm by omission. Further, the consideration of a patient’s wishes is fundamental for a good doctor–patient relationship. Following Andorno (2013), the argument against doctor’s involvement in their patients’ suicide is based on the risk of creating confusion about the proper aim of the medical profession (Andorno 2013). Some of the participants’ responses in this study alluded to the same reasoning: they fear assisted suicide could become a “common and frequent” procedure once they signal their acceptance. According to Martin et al. (2011), focusing on healing as the main aim of medicine is potentially ambiguous as this term does not completely subsume medical practice. There are many medical practices that are clearly not specifically healing in nature, but that are still regarded as ethically acceptable and compatible with the medical ethos. Martin et al. (2009) state that these measures are accepted because “providing care in accordance with the personal goals and values of the patient is an additional goal of medical practice besides healing”. Furthermore, the original definition of the aim of healing might be outdated and not fully apply to newer developments in aging societies (e.g. long term diseases where only palliative and not necessarily curative treatments are possible) (Martin et al. 2011).

Some of the participants stated that PAS would, in their opinion, not be requested if better palliation of pain and/or methods of decreasing psychological distress were made available. From the literature, it is known that there are three major factors in suffering at the end of life: pain and other physical symptoms, psychological distress, and existential distress (described as the experience of life without meaning) (Foley 1997). While there is some progress in undergraduate teaching on palliative care, as noted above, postgraduate training in Switzerland seldom covers the topic of PAS. Furthermore, Swiss data from 2008 suggests that physicians are inadequately trained in assessing and managing the multifactorial symptoms commonly associated with patients’ requests for PAS (Pereira et al. 2008). Training in palliative care is an obligatory part of the learning objectives in medical schools but only a few Swiss universities currently offer formal courses (Eychmüller et al. 2015). The average number of mandatory hours of palliative care education is 10.2 h, which falls significantly short of the 40 h recommended by the European Palliative Care Association’s Education Expert Group (Pereira et al. 2008; Eychmüller et al. 2015). An increase in the number of mandatory hours of palliative care education (ideally also covering the topic of PAS) could help to prepare GPs for handling of requests as well as supporting them when it comes to assessing in depth the origin of a patient’s wish for PAS. This is especially apparent when it is taken into consideration that other studies have shown that this training has positive effects (Gastmans et al. 2004). Perhaps even more so, considering studies have shown that patients’ decisions are highly influenced by the actual and perceived belief of pain relief (Foley 1991; Linton and Shaw 2011). Their consideration of requests for PAS was found to be directly linked with physical or psychological symptoms (Haverkate et al. 2001) which were also mentioned by some GPS in this study. It is therefore of utmost importance to handle requests professionally and to evaluate whether an assisted suicide request is made because of suffering that can possibly be alleviated through other methods. However, it is also important to note that more and more patients request PAS not only because of physical or psychological symptoms but because they fear losing their autonomy (Gamondi et al. 2013b; Fischer et al. 2009).

A key strength of this study is its use of a qualitative method to explore a multifaceted topic, enabling GPs to express their own attitudes towards PAS. However, the study sample may not have represented the full range of GPs’ views on the topic, since it was not specifically chosen to explore the issue of PAS. Other selection biases due to the recruitment process are possible as the study was announced under the title of “conditions and quality of end-of-life care in Switzerland—the role of general practitioners”. This announcement could result in a bias towards the participation of physicians who feel confident regarding palliative care and/or advance care planning.

While the topic of PAS is particularly sensitive, and may have legal implications, we recognize that GPs may prefer to avoid portraying a positive attitude towards PAS (social desirability). However, anonymity and congruency with other studies along with additional received statements that are not necessarily socially desirable (e.g. their general positive attitude towards PAS) lead us to conclude that this bias remains small. In order to gain better insight into communication about PAS in practice, we also considered the method of participant observation instead of interviews, as well as a combination of both methods. However, since requests for PAS are very infrequent and rather rare (the participating GPs received one to three requests for PAS during their career which is reflective of the national average), an observation of the conversation between GPs and their patients about PAS was not a feasible option due to the very limited timeframe of this study.