Manual of good dying | Canary Islands7

Activists from the Right to Die with Dignity platform celebrate the entry into force of the euthanasia law. / J. lizón / efe

With euthanasia already underway and without official data, the Spanish Society of Neurology drafts a document to guide doctors

Domenico Chiappe

Among the people who choose to advance the end of their lives are those with cancer, in the first place, followed by those with neurological diseases, according to data from countries where both euthanasia and assisted suicide are legal. In Spain, where it has been allowed since this year, there are no official figures but "the medical philosophy has already changed," says Francisco Escamilla, a neurologist at the Virgen de las Nieves University Hospital and a member of the Spanish Society of Neurology (SEN), who has published "a scientific and technical report" on euthanasia based on experience and debate in these months of legal implementation.

"In countries where its practice is legal, it affects the oncology specialty more and, with a growing trend, neurology," says Escamilla. Sooner or later we are going to face, for sure, some case, even annually and sometimes more, when treating diseases such as amyotrophic lateral sclerosis (ALS) and dementia ».

Spain being the seventh country to pass a law of this type, and the fourth in Europe, protocols have been developed, similar in most autonomous communities, on how to carry out euthanasia, choose and supply drugs, help in "assisted suicide at home level, which can be applied by relatives or the patient himself ». In some jurisdictions, a registry of conscientious objectors has been opened for the supply of the drug, but not to start the process as a responsible doctor, indicates Escamilla.

In some of the countries where euthanasia exists, most procedures start in primary care. The main factors related to the desire to hasten death are "fear of agony and suffocation, lack of hope, tiredness and a feeling of dependence," indicates the 'Basic Manual on the end of life and the law of Euthanasia'.

With “mild or moderate” dementia, half of the patients may “have their ability to decide altered”

In this report, which includes the point of view of the health professional, the "significant emotional impact" of the specialist is denounced, having to "debate between the duty to preserve the patient's life and that of alleviating intolerable suffering", but they defend that they should not be "forced to cross their own moral boundaries," says the report.

Faced with some uncertainty in an unprecedented service that is slowly advancing with opacity, neurologists have written a manual in which they estimate that, although "it is not considered a medical act" and "the law is being heavily debated", it is "a relief" for his "serious and incurable patients".

“The role of the doctor involves curing, relieving, palliating, but we also know that it can be one of the solutions for the suffering of patients”, explains Escamilla. «It implies a change of conception, independently of other types of nuances and individual inclinations, such as religious. Euthanasia is yet another right that is given to patients.”

Assess capabilities

Among the difficulties faced by neurologists is that of evaluating the decision-making capacity of some patients, such as those affected by Alzheimer's, for example. Even with "slight or moderate" symptoms, half of the patients may "have their ability to decide altered." When it is already in an advanced phase, the impossibility of discerning with wisdom reaches the totality. The law stipulates that they must have the ability to understand relevant information, recognize the consequences of treatments, have comparative reasoning about the different therapeutic possibilities and be able to communicate their decision.

“In dementia and psychiatric diseases it is difficult to assess the capacity of the patient, to discern whether the desire for death may be one more symptom of the disease and to predict the evolutionary course. These patients are extremely vulnerable people and the application of euthanasia must be subject to a close evaluation and evaluation of the cases,” the document warns.

In other neurological diseases, such as stroke, or psychiatric diseases, such as schizophrenia and depression, the mental decline ranges between 20% and 50%. Specialists recommend that the context be taken into account in the evaluation and criticize the fact that the Ministry of Health has developed an unusable test for those who suffer from "frontal brain damage".

"Even if it is done with witnesses, we are concerned about the patient's ability to carry out a document such as advance living wills, which is done in front of an official," says Escamilla. "Assessment of capacity can become quite complex." Neurologists criticize the "rush" with which the legislation was launched and call for "agile palliative care" to be offered to anyone interested in euthanasia, "being independent of one another."

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