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A Systematic Review of Stakeholder Perspectives of Dignity and Assisted Dying

  • Elaine Li Ying Quah
    Affiliations
    Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
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  • Keith Zi Yuan Chua
    Affiliations
    Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
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  • Jun Kiat Lua
    Affiliations
    Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
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  • Darius Wei Jun Wan
    Affiliations
    Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
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  • Chi Sum Chong
    Affiliations
    Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
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  • Yun Xue Lim
    Affiliations
    Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore
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  • Lalit Krishna
    Correspondence
    Address correspondence to: Lalit Krishna, Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool L3 9TA, United Kingdom.
    Affiliations
    Yong Loo Lin School of Medicine (E.L.Y.Q, K.Z.Y.C, J.K.L., D.W.J.W., C.S.C., Y.X.L., L.K), National University of Singapore, Singapore

    Division of Cancer Education (L.K), National Cancer Centre Singapore Singapore

    Division of Supportive and Palliative Care (L.K), National Cancer Centre Singapore (L.K), Singapore

    Palliative Care Institute Liverpool (L.K), Cancer Research Centre, University of Liverpool, Liverpool, United Kingdom

    Health Data Science (L.K), Liverpool

    Duke-NUS Medical School (L.K), Singapore

    Centre of Biomedical Ethics (L.K), Singapore

    PalC (L.K), The Palliative Care Centre for Excellence in Research and Education, Dover Park Hospice, Singapore
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Open AccessPublished:October 13, 2022DOI:https://doi.org/10.1016/j.jpainsymman.2022.10.004
A Systematic Review of Stakeholder Perspectives of Dignity and Assisted Dying
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      Abstract

      Introduction

      The debate on assisted dying and its components, euthanasia and physician-assisted suicide has evolved with the emergence of the right to dignity and the wish to hasten death (WTHD). Whilst shaped by local legal and sociocultural considerations, appreciation of how patients, healthcare professionals and lawmakers relate notions of dignity to self-concepts of personhood and the desire for assisted dying will better inform and direct support of patients.

      Methods

      Guided by the Systematic Evidence Based Approach, a systematic scoping review (SSR in SEBA) on perspectives of dignity, WTHD and personhood featured in PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Scopus databases and four key Palliative Care journals was conducted. The review hinged on the following questions: “what is the relationship between dignity and the wish to hasten death (WTHD) in the assisted dying debate?”, “how is dignity conceptualised by patients with WTHD?” and “what are prevailing perspectives on the role of assisted dying in maintaining a dying patient’s dignity?”

      Results

      6947 abstracts were identified, 663 full text articles reviewed, and 88 articles included. The four domains identified include 1) concepts of dignity through the lens of the Ring Theory of Personhood (RToP) including their various definitions and descriptions; 2) the relationship between dignity, WTHD and assisted dying with loss of dignity and autonomy foregrounded; 3) stakeholder perspectives for and against assisted dying including those of patient, healthcare provider and lawmaker; and 4) other dignity-conserving measures as alternatives to assisted dying.

      Conclusion

      Concepts of dignity constantly evolve throughout the patient's end of life journey. Understanding when and how these concepts of personhood change and trigger the fear of a loss of dignity or intractable suffering could direct timely, individualised and appropriate person-centred dignity conserving measures. We believe an RToP-based tool could fulfil this role and further study into the design of this tool is planned.

      Key Words

      Introduction

      Until recently, the debate on assisted dying and its components, euthanasia, and physician-assisted suicide, has been largely influenced by local legal, practical, social and cultural considerations.
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      Physician-assisted suicide refers to the act of providing a patient with lethal medication and/or the means to end their lives.
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      However, the introduction of the right to die and the maintenance of dignity for the terminally ill has seen views and requests for assisted dying change. Hendry et al,
      • Hendry M
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      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
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      Monteforte-Royo et al
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      and Rodriguez-Prat et al
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      found that the highly individualised requests by patients and their families for assisted dying were increasingly triggered by fears or the presence of a loss of dignity.
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      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
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      • Royo C
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      • Tomás-Sábado J
      • Mahtani V
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      PLoS One. 2012; 7: e37117
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      • Rodríguez-Prat A
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      These include irreversible physical deterioration, immobility, incontinence; failure to manage daily activities; limitations to or a loss of independence and autonomy; and/or compromises to one's personal, familial, professional, and societal roles.
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      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
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      • Royo C
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      • Balaguer A
      What lies behind the wish to hasten death? A systematic review and meta-ethnography from the perspective of patients.
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      • Rodríguez-Prat A
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      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      Determinations of intractable and/or ‘unbearable physical or mental suffering’ associated with an irretrievable loss of dignity are especially pertinent in the Netherlands, Belgium, Luxembourg, Switzerland, Canada, New Zealand and states such as Oregon, California, Colorado, District of Columbia, Hawaii, Maine, New Jersey, New Mexico, Vermont and Washington where it could lead to legally sanctioned access to assisted dying.
      • Emanuel EJ
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      • Urwin JW
      • Cohen J.
      Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe.
      JAMA: Journal of the American Medical Association. 2016; 316: 79-90
      Rodriguez-Prat and van Leeuwen
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      revealed that concepts of dignity within the assisted dying debate are not static but dynamic, complex, highly personalised, socially informed, and context dependent suggesting that these concepts evolve over the course of a disease and in different care, health, social, relational and personal circumstances. In turn, these postulations demand holistic, longitudinal, and personalised study of dignity. However, such studies have been limited.
      To help this process of understanding changing self-concepts of dignity, the research team built on links between self-concepts of dignity and notions of personhood or how patients conceive “what makes you, you” to posit that the Ring Theory of Personhood (RToP) could proffer a better appreciation of ties between self-concepts of personhood, dignity, WTHD and support or opposition to assisted dying.
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      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
      Palliat Med. 2013; 27: 13-26
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      A systematic scoping review on patients’ perceptions of dignity.
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      Perhaps more significantly, these authors suggest that the RToP could map changes in self-concepts of personhood as patients progress along their illness trajectories, providing physicians with a unique opportunity to address changing notions of dignity and direct timely, appropriate and personalised support to stakeholders confronting concerns over losses of dignity. This could prove invaluable in the care of patients in the Netherlands, Belgium and in states like Oregon and Washington where over 60% of requests for assisted dying relate to a loss of dignity.
      • Emanuel EJ
      • Onwuteaka-Philipsen BD
      • Urwin JW
      • Cohen J.
      Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe.
      JAMA: Journal of the American Medical Association. 2016; 316: 79-90

      The Ring Theory of Personhood

      The RToP posits that concepts of personhood may be represented by the Innate, Individual, Relational and Societal Rings. Each ring contains specific values, beliefs and principles that inform their corresponding identities.
      The Innate Identity is derived from the patient's Innate Ring which informs their thoughts, feelings, personality, narratives, conduct, values, beliefs, principles, biases, experiences, and decision-making processes in relation to their spiritual, religious and/or theist values, moral ideals, and ethical principles. The Individual Identity draws on the values, beliefs and principles surrounding the patient's conscious function contained within the Individual Ring. The Individual Identity is informed and informs the patient's narratives, experiences, and personality. The patient's Relational Identity is born of values, principles and beliefs governing their important personal relationships within their Relational Ring. The Societal Identity is shaped by the values, principles and beliefs informing their interactions with those people whom the patient deems do not share personal nor important relationships with them. The Societal Identity is also shaped by regnant societal, religious, professional, and legal expectations.

      Need for this Review

      Whilst it would be naïve to assume that all requests for assisted dying can be addressed through better appreciation and appropriate responses to distressing changes to self-concepts of personhood, these new insights do suggest that they may be helpful to some patients in this category, thus warranting closer attention. In the absence of studies into concepts of personhood, dignity, WTHD and assisted dying, we propose to study current arguments in the assisted dying debate through the lens of the RToP.

      Theoretical Lens

      The RToP's Innate, Individual, Relational and Societal elements embodies the notion of dignity as “an individual's intrinsic and inalienable right to respect, and a measure of self-worth and honour”.
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      • et al.
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      BMC Palliative Care. 2022; 21: 118
      ’s recent review on concepts of dignity amongst patients suggests that the RToP accounts for the influence of the patient's personal history, experiences and narratives “generated in the interactions between and amongst individuals, collectives and societies”.
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      postulate that the four rings of the RToP are sufficiently sensitive and adaptable to detect and map changes in concepts of personhood and thus guide support of evolving concepts of dignity.

      Methodology

      Krishna's Systematic Evidence Based Approach (SEBA) is adopted to guide this systematic scoping review (SSR) (henceforth SSR in SEBA).
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      Chia EWY, Huang H, Goh S, et al. A Systematic Scoping Review of Teaching and Evaluating Communications in The Intensive Care Unit. The Asia-Pacific Scholar. In Press.

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      Kuek JTY, Ngiam LXL, Kamal NHA, et al. The impact of caring for dying patients in intensive care units on a physician's personhood: a systematic scoping review. 2020;15:1-16.

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      SEBA's constructivist approach
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      and relativist lens
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      acknowledges dignity as a sociocultural construct “which considers both social and cultural constructs and the interrelationships between them”
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      enabling this SSR in SEBA to map current concepts of dignity across diverse settings, cultures, healthcare systems and legal mechanisms. Critically, this approach incorporates data from traditional peer-reviewed research-based publications and information from position, perspective, conference, reflective and opinion papers, editorials, commentaries, letters, posters, oral presentations, forum discussions, interviews, blogs, governmental reports, policy statements and surveys (grey literature).
      To provide a balanced review, an expert team comprised of a librarian from the National University of Singapore's (NUS) Yong Loo Lin School of Medicine (YLLSoM) and local educational experts and clinicians at YLLSoM, National Cancer Centre Singapore, Palliative Care Institute Liverpool, and Duke-NUS Medical School helped to oversee SEBA's 1) Systematic Approach, 2) Split Approach, 3) Jigsaw Perspective, 4) Funnelling Process 5) Analysis of data and non-data driven literature, and 6) Discussion Synthesis (Fig. 1).
      Fig 1
      Fig. 1The SEBA Process.
      Here we provide a brief description of SEBA's six-stages but include a more detailed description in the appendix (Supplementary File 1).

      Stage 1 of SEBA: Systematic Approach

      The SEBA methodology begins with the research and expert teams agreeing upon the research questions, the search terms, and the databases to be scrutinised. In this case, the primary research question was “what is the relationship between dignity and the wish to hasten death (WTHD) in the assisted dying debate?” The secondary research questions were: “how is dignity conceptualised by patients with WTHD?” and “what are prevailing perspectives on the role of assisted dying in maintaining a dying patient's dignity?”
      In keeping with SEBA, a PICOs (Population, Intervention, Comparison, Outcome, study design) format was adopted to guide the research process (Table 1). There was no comparison group.
      Table 1PICOS, Inclusion and Exclusion Criteria Applied to the Database Search
      PICOSInclusion CriteriaExclusion Criteria
      PopulationPatients receiving end-of-life care (i.e. palliative care patients)

      Patients with terminal illnesses or life-limiting conditions

      Healthcare professionals, defined by and limited to: doctors, nurses, medical social workers, physiotherapists and occupational therapists

      Caregivers      		Patients of non-medical specialties such as Veterinary, Dentistry, Alternative and Traditional Medicine

      Patients with non-terminal illnesses or non-life-limiting conditions
      InterventionProvision of avenues to perform euthanasia (active or passive), physician assisted suicide, mercy killingPractices such as palliative sedation

      Papers not mentioning euthanasia (active or passive), physician assisted suicide, or any interventions intended to prematurely end a patient's life
      ComparisonComparisons of patient, healthcare providers and lawmaker views on the effect dignity has on the want for assisted death

      Comparisons of patient, healthcare providers and lawmaker views on how the act of assisted dying affects dignity.      		N/A
      OutcomeHow the preservation of dignity affects patient views on assisted death

      How assisted death preserves dignity      		Outcomes not relevant to assisted death or dignity
      Study DesignArticles in English or translated to English

      All study designs including: mixed methods research, meta-analyses, systematic reviews, randomised controlled trials, cohort studies, case-control studies, cross-sectional studies, descriptive papers, guidelines, position, perspective, conference, reflective and opinion papers, editorials, commentaries, letters, posters, oral presentations, forum discussions, interviews, blogs, governmental reports, policy statements and surveys.

      Year of Publication: 2000-2021

      Databases: PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Scopus, CINAHL

      Journals: Journal of Pain and Symptom Management, BMC Palliative Medicine, Death Studies, Palliative Medicine      		Articles in languages other than English

      Publications before 1st January 2001 or after 31st December 2021
      Independent searches of PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Scopus databases were accompanied by hand searches of the Journal of Pain and Symptom Management, BMC Palliative Medicine, Death Studies, and Palliative Medicine. In keeping with Pham, Rajic
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      A scoping review of scoping reviews: advancing the approach and enhancing the consistency.
      Res Synthesis Methods. 2014; 5: 371-385
      ’s recommendations, the searches were restricted to articles published between January 1st 2001 and December 31st 2021 to accommodate existing manpower and time constraints. Quantitative, mixed and qualitative research methodologies meeting the inclusion criteria were included. With many current survey and assessment tools unable to capture the intricate connections and personalised nature of wider concepts of dignity, assisted dying, WTHD, personhood and identity, grey literature was included as a rich source of information. These resources capture wider patient, HCP and lawmaker perspectives and offer information on ethical, existential, and societal considerations often excluded by traditional systematic reviews as evidenced by recent reviews into how physicians and patients deal with death and dying and moral distress.
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      Stage 2 of SEBA: Split Approach

      Krishna's ‘Split Approach’
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      was employed to minimise oversight of key details, enhance the reliability of the analyses and provide a holistic picture of the included articles.
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      • Tay Kuang Teck
      • et al.
      Assessing mentoring: a scoping review of mentoring assessment tools in internal medicine between 1990 and 2019.
      PLoS One. 2020; 15e0232511
      , 
      • Peters MD
      • Godfrey CM
      • Khalil H
      • et al.
      Guidance for conducting systematic scoping reviews.
      Int J Evid Based Healthc. 2015; 13: 141-146
      This saw three groups of researchers independently analysing the included articles.
      The first team summarised and tabulated the included full-text articles to ensure that key aspects of the included articles were not lost (Supplementary File 2).
      Concurrently, the second team analysed the included articles using Braun and Clarke
      • Braun V
      • Clarke V.
      Using thematic analysis in psychology.
      Qualit Res Psychol. 2006; 3: 77-101
      ’s approach to thematic analysis.
      A third team employed Hsieh and Shannon
      • Hsieh H-F
      • Shannon SE.
      Three approaches to qualitative content analysis.
      Qual Health Res. 2005; 15: 1277-1288
      ’s approach to directed content analysis using a priori coding categories from Rodriguez-Prat's
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ‘Understanding patients’ experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography’ and Chua, Quah
      • Chua KZY
      • Quah ELY
      • Lim YX
      • et al.
      A systematic scoping review on patients’ perceptions of dignity.
      BMC Palliative Care. 2022; 21: 118
      ‘A systematic scoping review on patients’ perceptions of dignity’.
      Directed content analysis reduces omissions of negative findings seen with thematic analysis and draws to the fore key points of discussion in regnant literature.
      • Wen Jie Chua CWSC
      • Lee Fion Qian Hui
      • Koh Eugene Yong Hian
      Structuring mentoring in medicine and surgery. A systematic scoping review of mentoring programs between 2000 and 2019.
      J Contin Educ Health Prof. 2020; 40: 158-168
      , 
      • Yong Xiang Ng ZYKK
      • Yap Hong Wei
      • Tay Kuang Teck
      • et al.
      Assessing mentoring: a scoping review of mentoring assessment tools in internal medicine between 1990 and 2019.
      PLoS One. 2020; 15e0232511
      , 
      • Peters MD
      • Godfrey CM
      • Khalil H
      • et al.
      Guidance for conducting systematic scoping reviews.
      Int J Evid Based Healthc. 2015; 13: 141-146

      Stage 3 of SEBA: Jigsaw Perspective

      Guided by Phases 4 to 6 of France, Uny
      • France EF
      • Uny I
      • Ring N
      • et al.
      A methodological systematic review of meta-ethnography conduct to articulate the complex analytical phases.
      BMC Med Res Method. 2019; 19: 35
      ’s adaptation of Noblit, Hare

      Noblit GW, Hare RD, Hare RD. Meta-ethnography: Synthesizing qualitative studies: sage; 1988.

      ’s seven phases of meta-ethnography the themes and categories identified in the Split Approach were combined to create themes/categories.

      Stage 4 of SEBA: Funnelling Process

      The Funnelling Process employs Phases three to five of the seven phases to juxtapose the themes/categories with key messages identified in the tabulated summaries to create domains. These domains form the basis for ‘the line of argument’ in the discussion.

      Results

      6947 abstracts were identified from the six databases and hand searches of the four selected journals. 663 articles were reviewed, and 88 articles were included (Fig. 2). 34 articles were primary studies
      • Brinkman-Stoppelenburg A
      • Vergouwe Y
      • van der Heide A
      • Onwuteaka-Philipsen BD.
      Obligatory consultation of an independent physician on euthanasia requests in the Netherlands: what influences the SCEN physicians judgment of the legal requirements of due care?.
      Health Policy. 2014; 115: 75-81
      ,
      • Buiting H
      • van Delden J
      • Onwuteaka-Philpsen B
      • et al.
      Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.
      BMC Med Ethics. 2009; 10 (Vol 10 2009, ArtID 18)
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      N Engl J Med. 2000; 342: 557-563
      , 
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      , 
      • Robinson S
      • Kissane DW
      • Brooker J
      • Hempton C
      • Burney S.
      The relationship between poor quality of life and desire to hasten death: a multiple mediation model examining the contributions of depression, demoralization, loss of control, and low self-worth.
      J Pain Symptom Manage. 2017; 53: 243-249
      , 
      • Broom A.
      On euthanasia, resistance, and redemption: the moralities and politics of a hospice.
      Qual Health Res. 2012; 22: 226-237
      , 
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      Br J Neurosci Nurs. 2007; 3: 457-460
      , 
      • Oczkowski SJW
      • Crawshaw DE
      • Austin P
      • et al.
      How can we improve the experiences of patients and families who request medical assistance in dying? A multi-centre qualitative study.
      BMC Palliat Care. 2021; 20: 185
      , 
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      , 
      • Hizo-Abes P
      • Siegel L
      • Schreier G.
      Exploring attitudes toward physician-assisted death in patients with life-limiting illnesses with varying experiences of palliative care: a pilot study.
      BMC Palliative Care. 2018; 17: 56
      , 
      • Ganzini L
      • Goy ER
      • Dobscha SK.
      Why Oregon patients request assisted death: family members' views.
      J Gen Intern Med. 2008; 23: 154-157
      , 
      • Bahník Š
      • Vranka MA
      • Trefná K.
      What makes euthanasia justifiable? The role of symptoms' characteristics and interindividual differences.
      Death Stud. 2021; 45: 226-237
      , 
      • Ferrand E
      • Dreyfus JF
      • Chastrusse M
      • et al.
      Evolution of requests to hasten death among patients managed by palliative care teams in France: a multicentre cross-sectional survey (DemandE).
      Eur J Cancer. 2012; 48: 368-376
      , 
      • Comby M
      • Filbet M.
      The demand for euthanasia in palliative care units: a prospective study in seven units of the 'Rhone-Alpes' region.
      Palliat Med. 2005; 19: 587-593
      , 
      • Parpa E
      • Kostopoulou S
      • Tsilika E
      • et al.
      Psychometric properties of the greek version of the patient dignity inventory in advanced cancer patients.
      J Pain Symptom Manage. 2017; 54: 376-382
      , 
      • Asai A
      • Ohnishi M
      • Nagata SK
      • Tanida N
      • Yamazaki Y.
      Doctors' and nurses' attitudes towards and experiences of voluntary euthanasia: survey of members of the Japanese Association of Palliative Medicine.
      J Med Ethics. 2001; 27: 324-330
      , 
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      Eur J Gen Pract. 2014; 20: 25-31
      , 
      • van Tol D
      • Rietjens J
      • van der Heide A.
      Judgment of unbearable suffering and willingness to grant a euthanasia request by Dutch general practitioners.
      Health Policy. 2010; 97: 166-172
      , 
      • Ruijs CDM
      • van der Wal G
      • Kerkhof AJFM
      • Onwuteaka-Philipsen BD
      Unbearable suffering and requests for euthanasia prospectively studied in end-of-life cancer patients in primary care.
      BMC Palliative Care. 2014; 13: 62
      , 
      • Dees MK
      • Vernooij-Dassen MJ
      • Dekkers WJ
      • Vissers KC
      • van Weel C.
      'Unbearable suffering': a qualitative study on the perspectives of patients who request assistance in dying.
      J Med Ethics. 2011; 37: 727-734
      , 
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      Arch Intern Med. 2000; 160: 2454-2460
      , 
      • Coyle N
      • Sculco L.
      Expressed desire for hastened death in seven patients living with advanced cancer: a phenomenologic inquiry.
      Oncol Nurs Forum. 2004; 31: 699-709
      , 
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      Mortality. 2019; 24: 95-110
      , 
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      J Palliat Med. 2003; 6: 381-390
      , 
      • Crespo I
      • Rodríguez-Prat A
      • Monforte-Royo C
      • et al.
      Health-related quality of life in patients with advanced cancer who express a wish to hasten death: a comparative study.
      Palliat Med. 2020; 34: 630-638
      , 
      • Karlsson M
      • Milberg A
      • Strang P.
      Dying cancer patients' own opinions on euthanasia: an expression of autonomy? A qualitative study.
      Palliat Med. 2012; 26: 34-42
      , 
      • Ohnsorge K
      • Gudat H
      • Rehmann-Sutter C
      What a wish to die can mean: reasons, meanings and functions of wishes to die, reported from 30 qualitative case studies of terminally ill cancer patients in palliative care.
      BMC Palliat Care. 2014; 13: 38
      , 
      • Jiraphan A
      • Pitanupong J.
      General population-based study on preferences towards end-of-life care in Southern Thailand: a cross-sectional survey.
      BMC Palliative Care. 2022; 21: 36
      , 
      • Bolt EE
      • Pasman H
      • Deeg DJ
      • Onwuteaka-Philipsen BD
      From advance euthanasia directive to euthanasia: stable preference in older people?.
      J Am Geriatr Soc. 2016; 64: 1628-1633
      , 
      • Chapple A
      • Ziebland S
      • McPherson A
      • Herxheimer A.
      What people close to death say about euthanasia and assisted suicide: a qualitative study.
      J Med Ethics. 2006; 32: 706-710
      , 
      • Chochinov HM
      • Kristjanson LJ
      • Hack TF
      • et al.
      Burden to others and the terminally ill.
      J Pain Symptom Manage. 2007; 34: 463-471
      , 
      • Mesler MA
      • Miller PJ.
      Hospice and assisted suicide: the structure and process of an inherent dilemma.
      Death Stud. 2000; 24: 135-155
      , 
      • Achille MA
      • Ogloff JR.
      Attitudes toward and desire for assisted suicide among persons with amyotrophic lateral sclerosis.
      Omega: Journal of Death and Dying. 2003; 48: 1-21
      , 
      • Konishi E
      • Davis A.
      The right-to-die and the duty-to-die: Perceptions of nurses in the West and in Japan.
      Int Nurs Rev. 2001; 48: 17-28
      , 
      • Wang L
      • Elliott M
      • Henson LJ
      • et al.
      Death with dignity in Washington and Oregon patients with amyotrophic lateral sclerosis.
      Neurology. 2016; 86
      which were articles with original data, such as case studies, cross sectional studies and phenomenological studies. 14 articles were secondary studies
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      Asian J Psychiatr. 2021; 64102802
      ,
      • Hendry M
      • Pasterfield D
      • Lewis R
      • et al.
      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
      Palliat Med. 2013; 27: 13-26
      , 
      • Royo C
      • Villavicencio-Chávez C
      • Tomás-Sábado J
      • Mahtani V
      • Balaguer A
      What lies behind the wish to hasten death? A systematic review and meta-ethnography from the perspective of patients.
      PLoS One. 2012; 7: e37117
      , 
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      , 
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      Mortality. 2020; 25: 151-166
      , 
      • Dees M
      • Vernooij-Dassen M
      • Dekkers W
      • van Weel C.
      Review unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: an integrative review.
      Psychooncology. 2010; 19: 339-352
      , 
      • Cheung G
      • Sundram F.
      Who are the elderly who want to end their lives? [References]. Rational suicide in the elderly: Clinical, ethical, and sociocultural aspects.
      Springer International Publishing/Springer Nature; Switzerland, Cham, Switzerland2017: 113-128
      , 
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      Disabil Health J. 2010; 3: 3-15
      , 
      • Houska A
      • Loučka M.
      Patients' autonomy at the end of life: a critical review.
      J Pain Symptom Manage. 2019; 57: 835-845
      , 
      • Inbadas H
      • Zaman S
      • Whitelaw S
      • Clark D.
      Declarations on euthanasia and assisted dying.
      Death Stud. 2017; 41: 574-584
      , 
      • Fischer S
      • Huber CA
      • Furter M
      • et al.
      Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians.
      Swiss Med Wkly. 2009; 139: 333-338
      , 
      • Castelli Dransart DA
      • Lapierre S
      • Erlangsen A
      • et al.
      A systematic review of older adults' request for or attitude toward euthanasia or assisted-suicide.
      Aging Ment Health. 2021; 25: 420-430
      , 
      • Al Rabadi L
      • LeBlanc M
      • Bucy T
      • et al.
      Trends in medical aid in dying in Oregon and Washington.
      JAMA Network Open. 2019; 2 (e198648-e)
      which includes reviews and articles that discuss material originally presented elsewhere. 39 articles were tertiary articles
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      ,
      • Emanuel EJ
      • Onwuteaka-Philipsen BD
      • Urwin JW
      • Cohen J.
      Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe.
      JAMA: Journal of the American Medical Association. 2016; 316: 79-90
      ,
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      Med Care. 2008; 46: 1195-1197
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Kishore RR.
      Aruna Shanbaug and the right to die with dignity: the battle continues.
      Indian J Med Ethics. 2016; 1: 38-46
      , 
      • Ganzini L
      • Back A.
      From the USA: Understanding requests for physician-assisted death.
      Palliat Med. 2003; 17: 113-114
      , 
      • Ramsey C.
      The right to die: beyond academia.
      Monash Bioeth Rev. 2016; 34: 70-87
      , 
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      , 
      • Gamester N
      • Van den Eynden B
      The relationship between palliative care and legalized euthanasia in Belgium.
      J Palliat Med. 2009; 12: 589-591
      , 
      • Raus K
      • Sterckx S.
      Euthanasia for mental suffering. New directions in the ethics of assisted suicide and euthanasia.
      Springer International Publishing/Springer Nature; Switzerland, Cham, Switzerland2015: 79-96
      , 
      • Hiscox WE.
      Physician-assisted suicide in Oregon: The 'death with dignity' data.
      Med Law Int. 2007; 8: 197-220
      , 
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      Crit Care Med. 2017; 45: 149-155
      , 
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      Can Fam Physician. 2018; 64: 639-640
      , 
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      J Palliat Care. 2004; 20: 185-192
      , 
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      J Med Ethics. 2015; 41: 652-654
      , 
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      Clin Med (Lond). 2006; 6: 374-377
      , 
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      Am J Bioeth. 2022; 22: 51-58
      , 
      • Heintz AP.
      Euthanasia–or, death on request.
      J Psychosom Obstet Gynaecol. 2002; 23: 73-75
      , 
      • Gandsman A.
      Paradox of choice and the illusion of autonomy: the construction of ethical subjects in right-to-die activism.
      Death Stud. 2018; 42: 329-335
      , 
      • Rowe Iii MJ
      Beliefs.
      American Medical Association, Chicago, Illinois2015: 877-878
      , 
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      , 
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      , 
      • Finlay IG.
      Quality of life to the end.
      Commun Med. 2005; 2: 91-95
      , 
      • Clark D.
      Cultural considerations in planning palliative and end of life care.
      Palliat Med. 2012; 26: 195-196
      , 
      • Hale DB.
      A pretty pass: when is there a right to die?.
      Common Law World Rev. 2003; 32: 1-14
      , 
      • Fontalis A
      • Prousali E
      • Kulkarni K.
      Euthanasia and assisted dying: what is the current position and what are the key arguments informing the debate?.
      J R Soc Med. 2018; 111: 407-413
      , 
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      BMJ: British Medical Journal (Clinical Research Edition). 2012; 344 (e4007-e)
      , 
      • Dyer C.
      Dying woman loses her battle for assisted suicide.
      BMJ. 2002; 324: 1055
      , 
      • Eastaugh A.
      Choosing to die.
      Br J Gen Pract. 2012; 62: 96-97
      , 
      • Gentzler J.
      What is a death with dignity?.
      J Med Philos. 2003; 28: 461-487
      , 
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      , 
      • Freeman LM
      • Rose SL
      • Youngner SJ.
      Poverty: not a justification for banning physician-assisted death.
      Hastings Cent Rep. 2018; 48: 38-46
      , 
      • Kade WJ
      • Kade WJ.
      Death with dignity: a case study.
      Ann Intern Med. 2000; 132: 504-506
      , 
      • Roy DJ.
      Palliative care and euthanasia: a continuing need to think again.
      J Palliat Care. 2002; 18: 3-5
      , 
      • Friend ML.
      Physician-assisted suicide: death with dignity?.
      J Nurs Law. 2011; 14: 110-116
      , 
      • Abrahm JL.
      Patient and family requests for hastened death.
      Hematol Am Soc Hematol Educ Program. 2008; : 475-480
      , 
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      , 
      • Salladay SA.
      Christian ethics. Death with dignity?.
      J Christ Nurs. 2010; 27: 232
      , 
      Right to die–right or wrong?.
      Lancet Neurol. 2003; 2: 583
      which include guidelines, position, perspective, conference, reflective and opinion papers, editorials, commentaries, letters, posters, oral presentations, forum discussions, interviews, blogs, governmental reports, policy statements and surveys.
      Fig 2
      Fig. 2PRISMA Flowchart.
      The included articles’ setting, and legality of euthanasia and physician assisted suicide are summarised in Table 2.
      Table 2Setting of Included Articles
      CountryNumber of Articles
      Australia6
      Belgium3
      Canada6
      Chile1
      France2
      Germany2
      Greece1
      India1
      Japan1
      Netherlands11
      New Zealand2
      South Africa1
      Spain1
      Sweden1
      Switzerland4
      United Kingdom11
      United StatesMassachusetts1
      Oregon6
      Columbia1
      New York1
      Washington1
      Unstated6
      Mixed4
      Mixed14
      Unmentioned3
      PASEuthanasia
      Legal42Legal25
      Illegal26Illegal49
      Mixed21Mixed15
      Unmentioned3Unmentioned3
      The four domains identified include concepts of dignity through the lens of the RToP; the relationship between dignity, WTHD and assisted dying; patient, healthcare providers and lawmaker perspectives of dignity; and dignity-conserving measures.
      Our primary research question – “what is the relationship between dignity and the wish to hasten death (WTHD) in the assisted dying debate?” – was addressed in Domains one, two and three.
      Our secondary research questions – “how is dignity conceptualised by patients with WTHD?” and “what are prevailing perspectives on the role of assisted dying in maintaining a dying patient's dignity?” were addressed in Domains two and four.

      Domain 1: Concepts of Dignity

      Twenty-three of the 88 included articles provided a description of dignity.
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      ,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      Br J Neurosci Nurs. 2007; 3: 457-460
      ,
      • Bahník Š
      • Vranka MA
      • Trefná K.
      What makes euthanasia justifiable? The role of symptoms' characteristics and interindividual differences.
      Death Stud. 2021; 45: 226-237
      ,
      • Parpa E
      • Kostopoulou S
      • Tsilika E
      • et al.
      Psychometric properties of the greek version of the patient dignity inventory in advanced cancer patients.
      J Pain Symptom Manage. 2017; 54: 376-382
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      Mortality. 2019; 24: 95-110
      ,
      • Ohnsorge K
      • Gudat H
      • Rehmann-Sutter C
      What a wish to die can mean: reasons, meanings and functions of wishes to die, reported from 30 qualitative case studies of terminally ill cancer patients in palliative care.
      BMC Palliat Care. 2014; 13: 38
      ,
      • Chochinov HM
      • Kristjanson LJ
      • Hack TF
      • et al.
      Burden to others and the terminally ill.
      J Pain Symptom Manage. 2007; 34: 463-471
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      Mortality. 2020; 25: 151-166
      ,
      • Houska A
      • Loučka M.
      Patients' autonomy at the end of life: a critical review.
      J Pain Symptom Manage. 2019; 57: 835-845
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      J Palliat Care. 2004; 20: 185-192
      ,
      • Rowe Iii MJ
      Beliefs.
      American Medical Association, Chicago, Illinois2015: 877-878
      , 
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      , 
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      , 
      • Finlay IG.
      Quality of life to the end.
      Commun Med. 2005; 2: 91-95
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      BMJ: British Medical Journal (Clinical Research Edition). 2012; 344 (e4007-e)
      ,
      • Gentzler J.
      What is a death with dignity?.
      J Med Philos. 2003; 28: 461-487
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      When analysed individually through the lens of the RToP, some regnant definitions of dignity straddled more than one ring of the RToP.
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Parpa E
      • Kostopoulou S
      • Tsilika E
      • et al.
      Psychometric properties of the greek version of the patient dignity inventory in advanced cancer patients.
      J Pain Symptom Manage. 2017; 54: 376-382
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      Eight of the 23 definitions of dignity involved the Innate Ring
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Ohnsorge K
      • Gudat H
      • Rehmann-Sutter C
      What a wish to die can mean: reasons, meanings and functions of wishes to die, reported from 30 qualitative case studies of terminally ill cancer patients in palliative care.
      BMC Palliat Care. 2014; 13: 38
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      J Palliat Care. 2004; 20: 185-192
      ,
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      BMJ: British Medical Journal (Clinical Research Edition). 2012; 344 (e4007-e)
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      and touched upon the patient's intrinsic worth,
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      J Palliat Care. 2004; 20: 185-192
      ,
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      self-image
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      BMJ: British Medical Journal (Clinical Research Edition). 2012; 344 (e4007-e)
      and spirituality.
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Ohnsorge K
      • Gudat H
      • Rehmann-Sutter C
      What a wish to die can mean: reasons, meanings and functions of wishes to die, reported from 30 qualitative case studies of terminally ill cancer patients in palliative care.
      BMC Palliat Care. 2014; 13: 38
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      Seventeen definitions contained aspects in the Individual Ring
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      ,
      • Parpa E
      • Kostopoulou S
      • Tsilika E
      • et al.
      Psychometric properties of the greek version of the patient dignity inventory in advanced cancer patients.
      J Pain Symptom Manage. 2017; 54: 376-382
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      Mortality. 2019; 24: 95-110
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      Mortality. 2020; 25: 151-166
      ,
      • Houska A
      • Loučka M.
      Patients' autonomy at the end of life: a critical review.
      J Pain Symptom Manage. 2019; 57: 835-845
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Rowe Iii MJ
      Beliefs.
      American Medical Association, Chicago, Illinois2015: 877-878
      , 
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      , 
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      , 
      • Finlay IG.
      Quality of life to the end.
      Commun Med. 2005; 2: 91-95
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      BMJ: British Medical Journal (Clinical Research Edition). 2012; 344 (e4007-e)
      ,
      • Gentzler J.
      What is a death with dignity?.
      J Med Philos. 2003; 28: 461-487
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      and involved autonomous function. These included loss of control,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Houska A
      • Loučka M.
      Patients' autonomy at the end of life: a critical review.
      J Pain Symptom Manage. 2019; 57: 835-845
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      ,
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      ,
      • Gentzler J.
      What is a death with dignity?.
      J Med Philos. 2003; 28: 461-487
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      compromises to physical and cognitive capacity
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      and increased dependence on others.
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      Mortality. 2020; 25: 151-166
      ,
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      ,
      • Gentzler J.
      What is a death with dignity?.
      J Med Philos. 2003; 28: 461-487
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      These considerations are exacerbated by symptoms,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      Mortality. 2020; 25: 151-166
      ,
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      BMJ: British Medical Journal (Clinical Research Edition). 2012; 344 (e4007-e)
      futility of treatment,
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      treatment side-effects,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      the dying process
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      Mortality. 2019; 24: 95-110
      ,
      • Rowe Iii MJ
      Beliefs.
      American Medical Association, Chicago, Illinois2015: 877-878
      ,
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      ,
      • Finlay IG.
      Quality of life to the end.
      Commun Med. 2005; 2: 91-95
      ,
      • Gentzler J.
      What is a death with dignity?.
      J Med Philos. 2003; 28: 461-487
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      and limitations to the desired place of death.
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      Mortality. 2019; 24: 95-110
      Six definitions involved the Relational ring,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Parpa E
      • Kostopoulou S
      • Tsilika E
      • et al.
      Psychometric properties of the greek version of the patient dignity inventory in advanced cancer patients.
      J Pain Symptom Manage. 2017; 54: 376-382
      ,
      • Chochinov HM
      • Kristjanson LJ
      • Hack TF
      • et al.
      Burden to others and the terminally ill.
      J Pain Symptom Manage. 2007; 34: 463-471
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      acknowledging the import of close social connections,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      familial roles, responsibilities and respect.
      • Parpa E
      • Kostopoulou S
      • Tsilika E
      • et al.
      Psychometric properties of the greek version of the patient dignity inventory in advanced cancer patients.
      J Pain Symptom Manage. 2017; 54: 376-382
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      Being a burden on family also negatively impacted the Relational Ring and exacerbated a loss of dignity.
      • Chochinov HM
      • Kristjanson LJ
      • Hack TF
      • et al.
      Burden to others and the terminally ill.
      J Pain Symptom Manage. 2007; 34: 463-471
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      Five aspects of current definitions considered maintenance of societal roles and responsibilities within the Societal ring.
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      Br J Neurosci Nurs. 2007; 3: 457-460
      ,
      • Bahník Š
      • Vranka MA
      • Trefná K.
      What makes euthanasia justifiable? The role of symptoms' characteristics and interindividual differences.
      Death Stud. 2021; 45: 226-237
      ,
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      Dignity was developed through life via interpersonal relationships,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      Br J Neurosci Nurs. 2007; 3: 457-460
      ,
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      and having value to society.
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      A sense of self-burden was not just felt as an impact on those close to the patient, but also on the wider society.
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ,
      • Bahník Š
      • Vranka MA
      • Trefná K.
      What makes euthanasia justifiable? The role of symptoms' characteristics and interindividual differences.
      Death Stud. 2021; 45: 226-237
      Four elements impacted more than one ring. These were self-image,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      BMJ: British Medical Journal (Clinical Research Edition). 2012; 344 (e4007-e)
      a developing sense of respect through interpersonal interactions,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      Br J Neurosci Nurs. 2007; 3: 457-460
      ,
      • Allmark P.
      Death with dignity.
      J Med Ethics. 2002; 28: 255-257
      being a valuable member of society,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      and not being a burden to family and the wider society.
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      ,
      • Bahník Š
      • Vranka MA
      • Trefná K.
      What makes euthanasia justifiable? The role of symptoms' characteristics and interindividual differences.
      Death Stud. 2021; 45: 226-237

      Domain 2: Relationship between Dignity, WTHD and Assisted Dying

      A loss of or the fear of a loss of dignity and/or autonomy are amongst the biggest sources of WTHD.
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      Asian J Psychiatr. 2021; 64102802
      , 
      • Emanuel EJ
      • Onwuteaka-Philipsen BD
      • Urwin JW
      • Cohen J.
      Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe.
      JAMA: Journal of the American Medical Association. 2016; 316: 79-90
      , 
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      Med Care. 2008; 46: 1195-1197
      , 
      • Brinkman-Stoppelenburg A
      • Vergouwe Y
      • van der Heide A
      • Onwuteaka-Philipsen BD.
      Obligatory consultation of an independent physician on euthanasia requests in the Netherlands: what influences the SCEN physicians judgment of the legal requirements of due care?.
      Health Policy. 2014; 115: 75-81
      , 
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      , 
      • Buiting H
      • van Delden J
      • Onwuteaka-Philpsen B
      • et al.
      Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.
      BMC Med Ethics. 2009; 10 (Vol 10 2009, ArtID 18)
      , 
      • Hendry M
      • Pasterfield D
      • Lewis R
      • et al.
      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
      Palliat Med. 2013; 27: 13-26
      , 
      • Royo C
      • Villavicencio-Chávez C
      • Tomás-Sábado J
      • Mahtani V
      • Balaguer A
      What lies behind the wish to hasten death? A systematic review and meta-ethnography from the perspective of patients.
      PLoS One. 2012; 7: e37117
      , 
      • Rodríguez-Prat A
      • Balaguer A
      • Booth A
      • Monforte-Royo C
      Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography.
      BMJ Open. 2017; 7e016659
      , 
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      Med Health Care Philosophy. 2018; 21: 63-75
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      N Engl J Med. 2000; 342: 557-563
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      ,
      • Ganzini L
      • Goy ER
      • Dobscha SK.
      Why Oregon patients request assisted death: family members' views.
      J Gen Intern Med. 2008; 23: 154-157
      ,
      • Ferrand E
      • Dreyfus JF
      • Chastrusse M
      • et al.
      Evolution of requests to hasten death among patients managed by palliative care teams in France: a multicentre cross-sectional survey (DemandE).
      Eur J Cancer. 2012; 48: 368-376
      ,
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      Eur J Gen Pract. 2014; 20: 25-31
      ,
      • van Tol D
      • Rietjens J
      • van der Heide A.
      Judgment of unbearable suffering and willingness to grant a euthanasia request by Dutch general practitioners.
      Health Policy. 2010; 97: 166-172
      ,
      • Dees MK
      • Vernooij-Dassen MJ
      • Dekkers WJ
      • Vissers KC
      • van Weel C.
      'Unbearable suffering': a qualitative study on the perspectives of patients who request assistance in dying.
      J Med Ethics. 2011; 37: 727-734
      ,
      • Coyle N
      • Sculco L.
      Expressed desire for hastened death in seven patients living with advanced cancer: a phenomenologic inquiry.
      Oncol Nurs Forum. 2004; 31: 699-709
      ,
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      J Palliat Med. 2003; 6: 381-390
      , 
      • Crespo I
      • Rodríguez-Prat A
      • Monforte-Royo C
      • et al.
      Health-related quality of life in patients with advanced cancer who express a wish to hasten death: a comparative study.
      Palliat Med. 2020; 34: 630-638
      , 
      • Karlsson M
      • Milberg A
      • Strang P.
      Dying cancer patients' own opinions on euthanasia: an expression of autonomy? A qualitative study.
      Palliat Med. 2012; 26: 34-42
      ,
      • Bolt EE
      • Pasman H
      • Deeg DJ
      • Onwuteaka-Philipsen BD
      From advance euthanasia directive to euthanasia: stable preference in older people?.
      J Am Geriatr Soc. 2016; 64: 1628-1633
      ,
      • Chapple A
      • Ziebland S
      • McPherson A
      • Herxheimer A.
      What people close to death say about euthanasia and assisted suicide: a qualitative study.
      J Med Ethics. 2006; 32: 706-710
      ,
      • Konishi E
      • Davis A.
      The right-to-die and the duty-to-die: Perceptions of nurses in the West and in Japan.
      Int Nurs Rev. 2001; 48: 17-28
      , 
      • Wang L
      • Elliott M
      • Henson LJ
      • et al.
      Death with dignity in Washington and Oregon patients with amyotrophic lateral sclerosis.
      Neurology. 2016; 86
      , 
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      Mortality. 2020; 25: 151-166
      , 
      • Dees M
      • Vernooij-Dassen M
      • Dekkers W
      • van Weel C.
      Review unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: an integrative review.
      Psychooncology. 2010; 19: 339-352
      , 
      • Cheung G
      • Sundram F.
      Who are the elderly who want to end their lives? [References]. Rational suicide in the elderly: Clinical, ethical, and sociocultural aspects.
      Springer International Publishing/Springer Nature; Switzerland, Cham, Switzerland2017: 113-128
      , 
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      Disabil Health J. 2010; 3: 3-15
      ,
      • Fischer S
      • Huber CA
      • Furter M
      • et al.
      Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians.
      Swiss Med Wkly. 2009; 139: 333-338
      ,
      • Al Rabadi L
      • LeBlanc M
      • Bucy T
      • et al.
      Trends in medical aid in dying in Oregon and Washington.
      JAMA Network Open. 2019; 2 (e198648-e)
      ,
      • Kishore RR.
      Aruna Shanbaug and the right to die with dignity: the battle continues.
      Indian J Med Ethics. 2016; 1: 38-46
      ,
      • Ramsey C.
      The right to die: beyond academia.
      Monash Bioeth Rev. 2016; 34: 70-87
      , 
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      , 
      • Gamester N
      • Van den Eynden B
      The relationship between palliative care and legalized euthanasia in Belgium.
      J Palliat Med. 2009; 12: 589-591
      ,
      • Hiscox WE.
      Physician-assisted suicide in Oregon: The 'death with dignity' data.
      Med Law Int. 2007; 8: 197-220
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      Crit Care Med. 2017; 45: 149-155
      ,
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      J Med Ethics. 2015; 41: 652-654
      ,
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      Am J Bioeth. 2022; 22: 51-58
      ,
      • Rowe Iii MJ
      Beliefs.
      American Medical Association, Chicago, Illinois2015: 877-878
      ,
      • Hale DB.
      A pretty pass: when is there a right to die?.
      Common Law World Rev. 2003; 32: 1-14
      , 
      • Fontalis A
      • Prousali E
      • Kulkarni K.
      Euthanasia and assisted dying: what is the current position and what are the key arguments informing the debate?.
      J R Soc Med. 2018; 111: 407-413
      , 
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      BMJ: British Medical Journal (Clinical Research Edition). 2012; 344 (e4007-e)
      ,
      • Freeman LM
      • Rose SL
      • Youngner SJ.
      Poverty: not a justification for banning physician-assisted death.
      Hastings Cent Rep. 2018; 48: 38-46
      , 
      • Kade WJ
      • Kade WJ.
      Death with dignity: a case study.
      Ann Intern Med. 2000; 132: 504-506
      , 
      • Roy DJ.
      Palliative care and euthanasia: a continuing need to think again.
      J Palliat Care. 2002; 18: 3-5
      Unsurprisingly, attenuating these fears reduced WTHD.
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Crespo I
      • Rodríguez-Prat A
      • Monforte-Royo C
      • et al.
      Health-related quality of life in patients with advanced cancer who express a wish to hasten death: a comparative study.
      Palliat Med. 2020; 34: 630-638
      Gentzler
      • Gentzler J.
      What is a death with dignity?.
      J Med Philos. 2003; 28: 461-487
      argued that this can be accomplished simply by ensuring patients have the option to request for assisted dying.
      • Hendry M
      • Pasterfield D
      • Lewis R
      • et al.
      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
      Palliat Med. 2013; 27: 13-26
      ,
      • Coyle N
      • Sculco L.
      Expressed desire for hastened death in seven patients living with advanced cancer: a phenomenologic inquiry.
      Oncol Nurs Forum. 2004; 31: 699-709
      ,
      • Heintz AP.
      Euthanasia–or, death on request.
      J Psychosom Obstet Gynaecol. 2002; 23: 73-75
      ,
      • Gandsman A.
      Paradox of choice and the illusion of autonomy: the construction of ethical subjects in right-to-die activism.
      Death Stud. 2018; 42: 329-335
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      ,
      • Friend ML.
      Physician-assisted suicide: death with dignity?.
      J Nurs Law. 2011; 14: 110-116
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      Hematol Am Soc Hematol Educ Program. 2008; : 475-480
      Here, the option offers an ‘escape route’.
      Eight articles argued that access to assisted dying helped preserve patient's dignity
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      ,
      • Hendry M
      • Pasterfield D
      • Lewis R
      • et al.
      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
      Palliat Med. 2013; 27: 13-26
      ,
      • Coyle N
      • Sculco L.
      Expressed desire for hastened death in seven patients living with advanced cancer: a phenomenologic inquiry.
      Oncol Nurs Forum. 2004; 31: 699-709
      ,
      • Ramsey C.
      The right to die: beyond academia.
      Monash Bioeth Rev. 2016; 34: 70-87
      ,
      • Heintz AP.
      Euthanasia–or, death on request.
      J Psychosom Obstet Gynaecol. 2002; 23: 73-75
      ,
      • Gandsman A.
      Paradox of choice and the illusion of autonomy: the construction of ethical subjects in right-to-die activism.
      Death Stud. 2018; 42: 329-335
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      Am J Hospice Palliat Med. 2012; 29: 632-639
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      Hematol Am Soc Hematol Educ Program. 2008; : 475-480
      whilst three articles argued that the lack of such access exacerbated a loss of dignity.
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Kishore RR.
      Aruna Shanbaug and the right to die with dignity: the battle continues.
      Indian J Med Ethics. 2016; 1: 38-46
      ,
      • Dyer C.
      Two men plead with judges to let doctors end their life legally.
      BMJ: British Medical Journal (Clinical Research Edition). 2012; 344 (e4270-e)

      Domain 3: Patient, Healthcare Provider (HCP) and Lawmaker Perspectives for and against Assisted Dying

      Fifty-three articles reported on the position of patients, healthcare provider (HCP)s and lawmakers in support of and in opposition to assisted dying.

      Patient Perspectives

      Of the thirteen articles discussing patient perspectives, nine were in favour of assisted dying
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      ,
      • Hizo-Abes P
      • Siegel L
      • Schreier G.
      Exploring attitudes toward physician-assisted death in patients with life-limiting illnesses with varying experiences of palliative care: a pilot study.
      BMC Palliative Care. 2018; 17: 56
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      Arch Intern Med. 2000; 160: 2454-2460
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      Can Fam Physician. 2018; 64: 639-640
      ,
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      Am J Bioeth. 2022; 22: 51-58
      ,
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      ,
      Right to die–right or wrong?.
      Lancet Neurol. 2003; 2: 583
      while eight opposed it.
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      Med Care. 2008; 46: 1195-1197
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      Arch Intern Med. 2000; 160: 2454-2460
      ,
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      Three discussed its regulation.
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Hendry M
      • Pasterfield D
      • Lewis R
      • et al.
      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
      Palliat Med. 2013; 27: 13-26
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      Proponents of assisted dying focused firstly upon the patient's freedom of choice and their right to cease futile interventions,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      ,
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      Am J Bioeth. 2022; 22: 51-58
      end suffering
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      and determine their own death.
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      Arch Intern Med. 2000; 160: 2454-2460
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      Can Fam Physician. 2018; 64: 639-640
      ,
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      ,
      Right to die–right or wrong?.
      Lancet Neurol. 2003; 2: 583
      Patients opposed to assisted dying focused on ideological, moral, ethical, and religious positions.
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      Med Care. 2008; 46: 1195-1197
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      Arch Intern Med. 2000; 160: 2454-2460
      Yet perhaps the most cited opposition to assisted dying revolved around practical concerns. These include concerns over the validity of consent,
      • Hendry M
      • Pasterfield D
      • Lewis R
      • et al.
      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
      Palliat Med. 2013; 27: 13-26
      subjective judgement of a patient's quality of life,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      fears that legalisation of assisted dying would undermine patient-doctor trust
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      Med Care. 2008; 46: 1195-1197
      ,
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      and pressure vulnerable patients to accept assisted dying.
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      Soc Sci Med. 2008; 67: 647-656
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      Arch Intern Med. 2000; 160: 2454-2460

      Healthcare Provider Perspectives

      Thirty-six articles reported the views of healthcare providers (HCP)s. Sixteen articles were supportive of assisted dying.
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      , 
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      Asian J Psychiatr. 2021; 64102802
      , 
      • Emanuel EJ
      • Onwuteaka-Philipsen BD
      • Urwin JW
      • Cohen J.
      Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe.
      JAMA: Journal of the American Medical Association. 2016; 316: 79-90
      , 
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      Med Care. 2008; 46: 1195-1197
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Buiting H
      • van Delden J
      • Onwuteaka-Philpsen B
      • et al.
      Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.
      BMC Med Ethics. 2009; 10 (Vol 10 2009, ArtID 18)
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      N Engl J Med. 2000; 342: 557-563
      ,
      • Ganzini L
      • Goy ER
      • Dobscha SK.
      Why Oregon patients request assisted death: family members' views.
      J Gen Intern Med. 2008; 23: 154-157
      ,
      • Asai A
      • Ohnishi M
      • Nagata SK
      • Tanida N
      • Yamazaki Y.
      Doctors' and nurses' attitudes towards and experiences of voluntary euthanasia: survey of members of the Japanese Association of Palliative Medicine.
      J Med Ethics. 2001; 27: 324-330
      ,
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      Eur J Gen Pract. 2014; 20: 25-31
      ,
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      J Palliat Med. 2003; 6: 381-390
      ,
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      Disabil Health J. 2010; 3: 3-15
      ,
      • Fischer S
      • Huber CA
      • Furter M
      • et al.
      Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians.
      Swiss Med Wkly. 2009; 139: 333-338
      ,
      • Ramsey C.
      The right to die: beyond academia.
      Monash Bioeth Rev. 2016; 34: 70-87
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      Crit Care Med. 2017; 45: 149-155
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      Can Fam Physician. 2018; 64: 639-640
      ,
      • Rowe Iii MJ
      Beliefs.
      American Medical Association, Chicago, Illinois2015: 877-878
      ,
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      BMJ: British Medical Journal (Clinical Research Edition). 2012; 344 (e4007-e)
      ,
      • Eastaugh A.
      Choosing to die.
      Br J Gen Pract. 2012; 62: 96-97
      They focused on facilitating a good death for the patient,
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      Asian J Psychiatr. 2021; 64102802
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Buiting H
      • van Delden J
      • Onwuteaka-Philpsen B
      • et al.
      Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.
      BMC Med Ethics. 2009; 10 (Vol 10 2009, ArtID 18)
      ,
      • Ganzini L
      • Goy ER
      • Dobscha SK.
      Why Oregon patients request assisted death: family members' views.
      J Gen Intern Med. 2008; 23: 154-157
      ,
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      Eur J Gen Pract. 2014; 20: 25-31
      ,
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      J Palliat Med. 2003; 6: 381-390
      ,
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      Disabil Health J. 2010; 3: 3-15
      ,
      • Fischer S
      • Huber CA
      • Furter M
      • et al.
      Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians.
      Swiss Med Wkly. 2009; 139: 333-338
      ,
      • Ramsey C.
      The right to die: beyond academia.
      Monash Bioeth Rev. 2016; 34: 70-87
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      Crit Care Med. 2017; 45: 149-155
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      Can Fam Physician. 2018; 64: 639-640
      ,
      • Rowe Iii MJ
      Beliefs.
      American Medical Association, Chicago, Illinois2015: 877-878
      ,
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      respecting and fulfilling their autonomous desire for control
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Ganzini L
      • Goy ER
      • Dobscha SK.
      Why Oregon patients request assisted death: family members' views.
      J Gen Intern Med. 2008; 23: 154-157
      ,
      • Asai A
      • Ohnishi M
      • Nagata SK
      • Tanida N
      • Yamazaki Y.
      Doctors' and nurses' attitudes towards and experiences of voluntary euthanasia: survey of members of the Japanese Association of Palliative Medicine.
      J Med Ethics. 2001; 27: 324-330
      ,
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      Eur J Gen Pract. 2014; 20: 25-31
      ,
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      J Palliat Med. 2003; 6: 381-390
      ,
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      Disabil Health J. 2010; 3: 3-15
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      and ending their suffering.
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      Asian J Psychiatr. 2021; 64102802
      ,
      • Buiting H
      • van Delden J
      • Onwuteaka-Philpsen B
      • et al.
      Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.
      BMC Med Ethics. 2009; 10 (Vol 10 2009, ArtID 18)
      ,
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      Eur J Gen Pract. 2014; 20: 25-31
      ,
      • Fischer S
      • Huber CA
      • Furter M
      • et al.
      Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians.
      Swiss Med Wkly. 2009; 139: 333-338
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      Crit Care Med. 2017; 45: 149-155
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      Can Fam Physician. 2018; 64: 639-640
      ,
      • Rowe Iii MJ
      Beliefs.
      American Medical Association, Chicago, Illinois2015: 877-878
      Rodriquez
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      suggested that physicians may also see assisted dying as a means of circumventing the notion of abandonment by continuing to ‘journey with their patients’, as well as a means of reducing the burden upon caregivers and family.
      Twenty-three articles presented HCPs’ opposition of assisted dying.
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      ,
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      Asian J Psychiatr. 2021; 64102802
      ,
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      Med Care. 2008; 46: 1195-1197
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      N Engl J Med. 2000; 342: 557-563
      ,
      • Broom A.
      On euthanasia, resistance, and redemption: the moralities and politics of a hospice.
      Qual Health Res. 2012; 22: 226-237
      ,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      Br J Neurosci Nurs. 2007; 3: 457-460
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      Mortality. 2019; 24: 95-110
      ,
      • Ramsey C.
      The right to die: beyond academia.
      Monash Bioeth Rev. 2016; 34: 70-87
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Raus K
      • Sterckx S.
      Euthanasia for mental suffering. New directions in the ethics of assisted suicide and euthanasia.
      Springer International Publishing/Springer Nature; Switzerland, Cham, Switzerland2015: 79-96
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      Crit Care Med. 2017; 45: 149-155
      ,
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      J Med Ethics. 2015; 41: 652-654
      , 
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      Clin Med (Lond). 2006; 6: 374-377
      , 
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      Am J Bioeth. 2022; 22: 51-58
      ,
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      ,
      • Finlay IG.
      Quality of life to the end.
      Commun Med. 2005; 2: 91-95
      ,
      • Dyer C.
      Dying woman loses her battle for assisted suicide.
      BMJ. 2002; 324: 1055
      ,
      • Eastaugh A.
      Choosing to die.
      Br J Gen Pract. 2012; 62: 96-97
      ,
      • Freeman LM
      • Rose SL
      • Youngner SJ.
      Poverty: not a justification for banning physician-assisted death.
      Hastings Cent Rep. 2018; 48: 38-46
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      Hematol Am Soc Hematol Educ Program. 2008; : 475-480
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      ,
      • Fournier RR.
      Responses to life after death with dignity: the Oregon experience.
      Soc Work. 2000; 45: 467-468
      These include guilt,
      • Finlay IG.
      Quality of life to the end.
      Commun Med. 2005; 2: 91-95
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      Hematol Am Soc Hematol Educ Program. 2008; : 475-480
      grief
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      Mortality. 2019; 24: 95-110
      and emotional and moral distress
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      Asian J Psychiatr. 2021; 64102802
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      Br J Neurosci Nurs. 2007; 3: 457-460
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      Mortality. 2019; 24: 95-110
      ,
      • Ramsey C.
      The right to die: beyond academia.
      Monash Bioeth Rev. 2016; 34: 70-87
      ,
      • Raus K
      • Sterckx S.
      Euthanasia for mental suffering. New directions in the ethics of assisted suicide and euthanasia.
      Springer International Publishing/Springer Nature; Switzerland, Cham, Switzerland2015: 79-96
      ,
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      Clin Med (Lond). 2006; 6: 374-377
      ,
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      ,
      • Finlay IG.
      Quality of life to the end.
      Commun Med. 2005; 2: 91-95
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      Hematol Am Soc Hematol Educ Program. 2008; : 475-480
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      for transgressing regnant ethical and medical principles.
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      Asian J Psychiatr. 2021; 64102802
      ,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      Br J Neurosci Nurs. 2007; 3: 457-460
      ,
      • Ramsey C.
      The right to die: beyond academia.
      Monash Bioeth Rev. 2016; 34: 70-87
      ,
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      Clin Med (Lond). 2006; 6: 374-377
      ,
      • Drury B.
      The doctors of mercy.
      Men's Health. 2006; 21: 180-187
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      Others believed that assisted dying diminished the role of palliative care
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      and advocated instead for better palliative care
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      ,
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      Med Care. 2008; 46: 1195-1197
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      Crit Care Med. 2017; 45: 149-155
      ,
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      J Med Ethics. 2015; 41: 652-654
      ,
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      Clin Med (Lond). 2006; 6: 374-377
      ,
      • Eastaugh A.
      Choosing to die.
      Br J Gen Pract. 2012; 62: 96-97
      and improved quality of life.
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      Med Care. 2008; 46: 1195-1197
      ,
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      Clin Med (Lond). 2006; 6: 374-377
      Opposition amongst HCPs also revolved around the slippery slope argument that posits an eventual loosening of regulations
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      Mortality. 2019; 24: 95-110
      ,
      • Konishi E
      • Davis A.
      The right-to-die and the duty-to-die: Perceptions of nurses in the West and in Japan.
      Int Nurs Rev. 2001; 48: 17-28
      ,
      • Raus K
      • Sterckx S.
      Euthanasia for mental suffering. New directions in the ethics of assisted suicide and euthanasia.
      Springer International Publishing/Springer Nature; Switzerland, Cham, Switzerland2015: 79-96
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      Can Fam Physician. 2018; 64: 639-640
      and the application of assisted dying upon the vulnerable.
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      Am J Bioeth. 2022; 22: 51-58
      ,
      • Freeman LM
      • Rose SL
      • Youngner SJ.
      Poverty: not a justification for banning physician-assisted death.
      Hastings Cent Rep. 2018; 48: 38-46
      HCPs point to inconsistencies in the understanding of many of the terms involved in current legislation to back these posits,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      Mortality. 2019; 24: 95-110
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      Can Fam Physician. 2018; 64: 639-640
      along with vagaries surrounding prognostication,
      • Raus K
      • Sterckx S.
      Euthanasia for mental suffering. New directions in the ethics of assisted suicide and euthanasia.
      Springer International Publishing/Springer Nature; Switzerland, Cham, Switzerland2015: 79-96
      the subjectivity of quality of life determinations
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      and concerns over the influence and impact upon the family
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      Mortality. 2019; 24: 95-110
      ,
      • Konishi E
      • Davis A.
      The right-to-die and the duty-to-die: Perceptions of nurses in the West and in Japan.
      Int Nurs Rev. 2001; 48: 17-28
      to counter evidence that no evidence of slippery slopes have been reported.

      Lawmaker Perspectives

      The seven papers containing perspectives of lawmakers focus on societal rights, and the protection of vulnerable groups. Those in favour of assisted dying
      • Kishore RR.
      Aruna Shanbaug and the right to die with dignity: the battle continues.
      Indian J Med Ethics. 2016; 1: 38-46
      ,
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      Am J Bioeth. 2022; 22: 51-58
      ,
      • Hale DB.
      A pretty pass: when is there a right to die?.
      Common Law World Rev. 2003; 32: 1-14
      tended to be from countries where it was legal. Dutch proponents posited that assisted dying provided a compassionate end of suffering
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      Am J Bioeth. 2022; 22: 51-58
      ,
      • Hale DB.
      A pretty pass: when is there a right to die?.
      Common Law World Rev. 2003; 32: 1-14
      whilst commentators in New Mexico, West Australia, South Australia, Switzerland, and Canada supported patients’ constitutional rights to obtain aid in dying.
      • Kishore RR.
      Aruna Shanbaug and the right to die with dignity: the battle continues.
      Indian J Med Ethics. 2016; 1: 38-46
      Swiss lawmakers also espoused respect for the patients’ right to end their lives and their right to govern their private lives.
      • Kishore RR.
      Aruna Shanbaug and the right to die with dignity: the battle continues.
      Indian J Med Ethics. 2016; 1: 38-46
      Conversely, the European Court of Human Rights declined to extend the Human Right Act of 1998 to include the right to death in the case of Diane Pretty,

      Rights ECoH. End of life and the European Convention on Human Rights 2022. p. https://www.echr.coe.int/documents/fs_euthanasia_eng.pdf.

      maintaining that it would undermine the protection of life and lead to abuse of Assisted Dying.
      • Kishore RR.
      Aruna Shanbaug and the right to die with dignity: the battle continues.
      Indian J Med Ethics. 2016; 1: 38-46
      ,
      • Hale DB.
      A pretty pass: when is there a right to die?.
      Common Law World Rev. 2003; 32: 1-14
      ,
      • Dyer C.
      Dying woman loses her battle for assisted suicide.
      BMJ. 2002; 324: 1055
      In Haas v Switzerland, the European Court of Human Rights maintained that a person wishing to commit suicide should not be allowed to do so hastily and that the government of Switzerland was correct in maintaining stringent requirements before patients were provided access to sodium pentobarbital for the purposes of hastening their demise. This would be consistent with governmental responsibilities to ensure that such decisions are neither hasty nor coerced particularly when Kishore94 reports of lawmakers in the USA advocating for assisted dying to protect healthcare resources.

      Domain 4: Dignity-Conserving Care

      Forty-four articles made reference to alternatives to assisted dying. Twenty-two proposed palliative care interventions,
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      Linacre Q. 2001; 68: 251-261
      ,
      • Emanuel EJ
      • Onwuteaka-Philipsen BD
      • Urwin JW
      • Cohen J.
      Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe.
      JAMA: Journal of the American Medical Association. 2016; 316: 79-90
      ,
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      Med Care. 2008; 46: 1195-1197
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      Lancet Neurol. 2003; 2: 637-643
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      N Engl J Med. 2000; 342: 557-563
      ,
      • Broom A.
      On euthanasia, resistance, and redemption: the moralities and politics of a hospice.
      Qual Health Res. 2012; 22: 226-237
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      ,
      • Comby M
      • Filbet M.
      The demand for euthanasia in palliative care units: a prospective study in seven units of the 'Rhone-Alpes' region.
      Palliat Med. 2005; 19: 587-593
      ,
      • Crespo I
      • Rodríguez-Prat A
      • Monforte-Royo C
      • et al.
      Health-related quality of life in patients with advanced cancer who express a wish to hasten death: a comparative study.
      Palliat Med. 2020; 34: 630-638
      ,
      • Chapple A
      • Ziebland S
      • McPherson A
      • Herxheimer A.
      What people close to death say about euthanasia and assisted suicide: a qualitative study.
      J Med Ethics. 2006; 32: 706-710
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      Mortality. 2020; 25: 151-166
      ,
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      Disabil Health J. 2010; 3: 3-15
      ,
      • Ganzini L
      • Back A.
      From the USA: Understanding requests for physician-assisted death.
      Palliat Med. 2003; 17: 113-114
      , 
      • Ramsey C.
      The right to die: beyond academia.
      Monash Bioeth Rev. 2016; 34: 70-87
      , 
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      J Med Ethics. 2021;
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      Can Fam Physician. 2018; 64: 639-640
      , 
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      J Palliat Care. 2004; 20: 185-192
      , 
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      J Med Ethics. 2015; 41: 652-654
      , 
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      Clin Med (Lond). 2006; 6: 374-377
      ,
      • Friend ML.
      Physician-assisted suicide: death with dignity?.
      J Nurs Law. 2011; 14: 110-116
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      Hematol Am Soc Hematol Educ Program. 2008; : 475-480
      ,
      • Salladay SA.
      Christian ethics. Death with dignity?.
      J Christ Nurs. 2010; 27: 232
      better access to expert palliative care.
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      ,
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      J Palliat Care. 2004; 20: 185-192
      ,
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      J Med Ethics. 2015; 41: 652-654
      ,
      • Freeman LM
      • Rose SL
      • Youngner SJ.
      Poverty: not a justification for banning physician-assisted death.
      Hastings Cent Rep. 2018; 48: 38-46
      Seven articles espoused that improved social support would reduce WTHD.
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      N Engl J Med. 2000; 342: 557-563
      ,
      • Coyle N
      • Sculco L.
      Expressed desire for hastened death in seven patients living with advanced cancer: a phenomenologic inquiry.
      Oncol Nurs Forum. 2004; 31: 699-709
      ,
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      J Palliat Med. 2003; 6: 381-390
      ,
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      Disabil Health J. 2010; 3: 3-15
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      Crit Care Med. 2017; 45: 149-155
      ,
      • Finlay IG.
      Quality of life to the end.
      Commun Med. 2005; 2: 91-95
      ,
      • Roy DJ.
      Palliative care and euthanasia: a continuing need to think again.
      J Palliat Care. 2002; 18: 3-5
      Twenty-one articles propose the use of dignity-conserving measures to control physical,
      • Hendry M
      • Pasterfield D
      • Lewis R
      • et al.
      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
      Palliat Med. 2013; 27: 13-26
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      N Engl J Med. 2000; 342: 557-563
      ,
      • Broom A.
      On euthanasia, resistance, and redemption: the moralities and politics of a hospice.
      Qual Health Res. 2012; 22: 226-237
      ,
      • Asai A
      • Ohnishi M
      • Nagata SK
      • Tanida N
      • Yamazaki Y.
      Doctors' and nurses' attitudes towards and experiences of voluntary euthanasia: survey of members of the Japanese Association of Palliative Medicine.
      J Med Ethics. 2001; 27: 324-330
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      Mortality. 2020; 25: 151-166
      ,
      • Gentzler J.
      What is a death with dignity?.
      J Med Philos. 2003; 28: 461-487
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      psychological,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      N Engl J Med. 2000; 342: 557-563
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      Arch Intern Med. 2000; 160: 2454-2460
      and existential issues,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      N Engl J Med. 2000; 342: 557-563
      ,
      • Robinson S
      • Kissane DW
      • Brooker J
      • Hempton C
      • Burney S.
      The relationship between poor quality of life and desire to hasten death: a multiple mediation model examining the contributions of depression, demoralization, loss of control, and low self-worth.
      J Pain Symptom Manage. 2017; 53: 243-249
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      Health Psychol. 2007; 26: 314-323
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      Arch Intern Med. 2000; 160: 2454-2460
      enhance pain control
      • Hendry M
      • Pasterfield D
      • Lewis R
      • et al.
      Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying.
      Palliat Med. 2013; 27: 13-26
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      N Engl J Med. 2000; 342: 557-563
      ,
      • Broom A.
      On euthanasia, resistance, and redemption: the moralities and politics of a hospice.
      Qual Health Res. 2012; 22: 226-237
      ,
      • Asai A
      • Ohnishi M
      • Nagata SK
      • Tanida N
      • Yamazaki Y.
      Doctors' and nurses' attitudes towards and experiences of voluntary euthanasia: survey of members of the Japanese Association of Palliative Medicine.
      J Med Ethics. 2001; 27: 324-330
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      Mortality. 2020; 25: 151-166
      ,
      • Gentzler J.
      What is a death with dignity?.
      J Med Philos. 2003; 28: 461-487
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Trends Anaesthesia Crit Care. 2016; 10: 7-14
      and improve a patient's quality of life.
      • Konishi E
      • Davis A.
      The right-to-die and the duty-to-die: Perceptions of nurses in the West and in Japan.
      Int Nurs Rev. 2001; 48: 17-28
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      Crit Care Med. 2017; 45: 149-155
      ,
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      J Palliat Care. 2004; 20: 185-192
      ,
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      Clin Med (Lond). 2006; 6: 374-377
      ,
      • Finlay IG.
      Quality of life to the end.
      Commun Med. 2005; 2: 91-95