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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

      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.
      • Soh TL
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      Responding to calls to legalise euthanasia and physician-assisted suicide in Singapore.
      It has also been largely confined to patients with limited prognoses. Here, euthanasia refers to the intentional administration of lethal drugs by a physician to end a patient's life.
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      • 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.
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      • 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?.
      Physician-assisted suicide refers to the act of providing a patient with lethal medication and/or the means to end their lives.
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Buiting H
      • van Delden J
      • Onwuteaka-Philpsen B
      • et al.
      Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.
      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
      • 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.
      Monteforte-Royo et al
      • 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.
      and Rodriguez-Prat et al
      • 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.
      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.
      • 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.
      • 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.
      • 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.
      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.
      • 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.
      • 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.
      • 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.
      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
      • Onwuteaka-Philipsen BD
      • Urwin JW
      • Cohen J.
      Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe.
      Rodriguez-Prat and van Leeuwen
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      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.
      • 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.
      ,
      • Chua KZY
      • Quah ELY
      • Lim YX
      • et al.
      A systematic scoping review on patients’ perceptions of dignity.
      • Popay J
      • Roberts H
      • Sowden A
      • et al.
      Guidance on the conduct of narrative synthesis in systematic reviews.
      • Pring R.
      The ‘False Dualism’ of educational research.

      Crotty M. The foundations of social research: meaning and perspective in the research process: Sage; 1998 Oct 15.

      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.

      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”.
      • Chua KZY
      • Quah ELY
      • Lim YX
      • et al.
      A systematic scoping review on patients’ perceptions of dignity.
      Chua, Quah
      • Chua KZY
      • Quah ELY
      • Lim YX
      • et al.
      A systematic scoping review on patients’ perceptions of dignity.
      ’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”.
      • Wei SS
      • Krishna LKR.
      Respecting the wishes of incapacitated patients at the end of life.
      Importantly, Chua, Quah
      • Chua KZY
      • Quah ELY
      • Lim YX
      • et al.
      A systematic scoping review on patients’ perceptions of dignity.
      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).
      • Kow CS
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      A systematic scoping review of ethical issues in mentoring in medical schools.
      • Ngiam LXL
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      • et al.
      Impact of caring for terminally ill children on physicians: a systematic scoping review.
      • Krishna LKR
      • Tan LHE
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      • et al.
      Enhancing mentoring in palliative care: an evidence based mentoring framework.
      • Bok C
      • Ng CH
      • Koh JWH
      • et al.
      Interprofessional communication (IPC) for medical students: a scoping review.

      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.

      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.

      • Hong DZ
      • Lim AJS
      • Tan R
      • et al.
      A systematic scoping review on portfolios of medical educators.
      • Goh S
      • Wong RSM
      • Quah ELY
      • et al.
      Mentoring in palliative medicine in the time of covid-19: a systematic scoping review.
      SEBA's constructivist approach
      • Ng YX
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      • Yap HW
      • et al.
      Assessing mentoring: a scoping review of mentoring assessment tools in internal medicine between 1990 and 2019.
      • Bousquet J
      • Schunemann HJ
      • Samolinski B
      • et al.
      Allergic Rhinitis and its Impact on Asthma (ARIA): achievements in 10 years and future needs.
      • Nur Haidah Ahmad Kamal LHET
      • Wong Ruth Si Man
      • Ong Ryan Rui Song
      Enhancing education in palliative medicine: the role of systematic scoping reviews.
      • Ryan Rui Song Ong REWS
      • Wong Ruth Si Man
      A systematic scoping review of narrative reviews in palliative medicine education.
      • Zheng Hui Mah RSMW
      • Loh Ryan Ern Wei Seow Eleanor Kei Ying
      • Haidah Nur
      • et al.
      A systematic scoping review of systematic reviews in palliative medicine education.
      and relativist lens
      • Ford DW
      • Downey L
      • Engelberg R
      • Back AL
      • Curtis JR.
      Discussing religion and spirituality is an advanced communication skill: an exploratory structural equation model of physician trainee self-ratings.
      • Schick-Makaroff K
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      What synthesis methodology should I use? A review and analysis of approaches to research synthesis.
      acknowledges dignity as a sociocultural construct “which considers both social and cultural constructs and the interrelationships between them”
      • Deshpande AD
      • Sanders Thompson VL
      • Vaughn KP
      • Kreuter MW
      The use of sociocultural constructs in cancer screening research among African Americans.
      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).
      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
      • Pham MT
      • Rajic A
      • Greig JD
      • et al.
      A scoping review of scoping reviews: advancing the approach and enhancing the consistency.
      ’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.
      • Chua KZY
      • Quah ELY
      • Lim YX
      • et al.
      A systematic scoping review on patients’ perceptions of dignity.
      ,
      • Ong RSR
      • Wong RSM
      • Chee RCH
      • et al.
      A systematic scoping review moral distress amongst medical students.
      • Ho CY
      • Lim NA
      • Ong YT
      • et al.
      The impact of death and dying on the personhood of senior nurses at the National Cancer Centre Singapore (NCCS): a qualitative study.
      • Chiam M
      • Ho CY
      • Quah E
      • et al.
      Changing self-concept in the time of COVID-19: a close look at physician reflections on social media.
      • Chan NPX
      • Chia JL
      • Ho CY
      • et al.
      Extending the ring theory of personhood to the care of dying patients in intensive care units.
      • Huang H
      • Toh RQE
      • Chiang CLL
      • et al.
      Impact of dying neonates on doctors' and nurses' personhood: a systematic scoping review.
      • Vig PS
      • Lim JY
      • Lee RWL
      • et al.
      Parental bereavement – impact of death of neonates and children under 12 years on personhood of parents: a systematic scoping review.
      • Ho CY
      • Kow CS
      • Chia CHJ
      • et al.
      The impact of death and dying on the personhood of medical students: a systematic scoping review.

      Stage 2 of SEBA: Split Approach

      Krishna's ‘Split Approach’
      • Pham MT
      • Rajic A
      • Greig JD
      • et al.
      A scoping review of scoping reviews: advancing the approach and enhancing the consistency.
      ,
      • 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.
      • 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.
      • Peters MD
      • Godfrey CM
      • Khalil H
      • et al.
      Guidance for conducting systematic scoping reviews.
      • Sandelowski M
      • Barroso J.
      Handbook for synthesizing qualitative research.
      • Sambunjak D
      • Straus SE
      • Marusic A.
      A systematic review of qualitative research on the meaning and characteristics of mentoring in academic medicine.
      was employed to minimise oversight of key details, enhance the reliability of the analyses and provide a holistic picture of the included articles.
      • 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.
      • 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.
      • Peters MD
      • Godfrey CM
      • Khalil H
      • et al.
      Guidance for conducting systematic scoping reviews.
      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.
      ’s approach to thematic analysis.
      A third team employed Hsieh and Shannon
      • Hsieh H-F
      • Shannon SE.
      Three approaches to qualitative content analysis.
      ’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.
      ‘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.
      ‘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.
      • 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.
      • Peters MD
      • Godfrey CM
      • Khalil H
      • et al.
      Guidance for conducting systematic scoping reviews.

      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.
      ’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?.
      ,
      • Buiting H
      • van Delden J
      • Onwuteaka-Philpsen B
      • et al.
      Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      • 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.
      • Broom A.
      On euthanasia, resistance, and redemption: the moralities and politics of a hospice.
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      • 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.
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      • 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.
      • Ganzini L
      • Goy ER
      • Dobscha SK.
      Why Oregon patients request assisted death: family members' views.
      • Bahník Š
      • Vranka MA
      • Trefná K.
      What makes euthanasia justifiable? The role of symptoms' characteristics and interindividual differences.
      • 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).
      • Comby M
      • Filbet M.
      The demand for euthanasia in palliative care units: a prospective study in seven units of the 'Rhone-Alpes' region.
      • Parpa E
      • Kostopoulou S
      • Tsilika E
      • et al.
      Psychometric properties of the greek version of the patient dignity inventory in advanced cancer patients.
      • 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.
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      • van Tol D
      • Rietjens J
      • van der Heide A.
      Judgment of unbearable suffering and willingness to grant a euthanasia request by Dutch general practitioners.
      • 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.
      • 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.
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      • Coyle N
      • Sculco L.
      Expressed desire for hastened death in seven patients living with advanced cancer: a phenomenologic inquiry.
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      • 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.
      • Karlsson M
      • Milberg A
      • Strang P.
      Dying cancer patients' own opinions on euthanasia: an expression of autonomy? A qualitative study.
      • 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.
      • Jiraphan A
      • Pitanupong J.
      General population-based study on preferences towards end-of-life care in Southern Thailand: a cross-sectional survey.
      • Bolt EE
      • Pasman H
      • Deeg DJ
      • Onwuteaka-Philipsen BD
      From advance euthanasia directive to euthanasia: stable preference in older people?.
      • Chapple A
      • Ziebland S
      • McPherson A
      • Herxheimer A.
      What people close to death say about euthanasia and assisted suicide: a qualitative study.
      • Chochinov HM
      • Kristjanson LJ
      • Hack TF
      • et al.
      Burden to others and the terminally ill.
      • Mesler MA
      • Miller PJ.
      Hospice and assisted suicide: the structure and process of an inherent dilemma.
      • Achille MA
      • Ogloff JR.
      Attitudes toward and desire for assisted suicide among persons with amyotrophic lateral sclerosis.
      • Konishi E
      • Davis A.
      The right-to-die and the duty-to-die: Perceptions of nurses in the West and in Japan.
      • Wang L
      • Elliott M
      • Henson LJ
      • et al.
      Death with dignity in Washington and Oregon patients with amyotrophic lateral sclerosis.
      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.
      ,
      • 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.
      • 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.
      • 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.
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      • 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.
      • 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.
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      • Houska A
      • Loučka M.
      Patients' autonomy at the end of life: a critical review.
      • Inbadas H
      • Zaman S
      • Whitelaw S
      • Clark D.
      Declarations on euthanasia and assisted dying.
      • Fischer S
      • Huber CA
      • Furter M
      • et al.
      Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians.
      • Castelli Dransart DA
      • Lapierre S
      • Erlangsen A
      • et al.
      A systematic review of older adults' request for or attitude toward euthanasia or assisted-suicide.
      • Al Rabadi L
      • LeBlanc M
      • Bucy T
      • et al.
      Trends in medical aid in dying in Oregon and Washington.
      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.
      ,
      • 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.
      ,
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Kishore RR.
      Aruna Shanbaug and the right to die with dignity: the battle continues.
      • Ganzini L
      • Back A.
      From the USA: Understanding requests for physician-assisted death.
      • Ramsey C.
      The right to die: beyond academia.
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      • Gamester N
      • Van den Eynden B
      The relationship between palliative care and legalized euthanasia in Belgium.
      • Raus K
      • Sterckx S.
      Euthanasia for mental suffering. New directions in the ethics of assisted suicide and euthanasia.
      • Hiscox WE.
      Physician-assisted suicide in Oregon: The 'death with dignity' data.
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      • Heintz AP.
      Euthanasia–or, death on request.
      • Gandsman A.
      Paradox of choice and the illusion of autonomy: the construction of ethical subjects in right-to-die activism.
      • Rowe Iii MJ
      Beliefs.
      • Drury B.
      The doctors of mercy.
      • Allmark P.
      Death with dignity.
      • Finlay IG.
      Quality of life to the end.
      • Clark D.
      Cultural considerations in planning palliative and end of life care.
      • Hale DB.
      A pretty pass: when is there a right to die?.
      • Fontalis A
      • Prousali E
      • Kulkarni K.
      Euthanasia and assisted dying: what is the current position and what are the key arguments informing the debate?.
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      • Dyer C.
      Dying woman loses her battle for assisted suicide.
      • Eastaugh A.
      Choosing to die.
      • Gentzler J.
      What is a death with dignity?.
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      • Freeman LM
      • Rose SL
      • Youngner SJ.
      Poverty: not a justification for banning physician-assisted death.
      • Kade WJ
      • Kade WJ.
      Death with dignity: a case study.
      • Roy DJ.
      Palliative care and euthanasia: a continuing need to think again.
      • Friend ML.
      Physician-assisted suicide: death with dignity?.
      • Abrahm JL.
      Patient and family requests for hastened death.
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      • Salladay SA.
      Christian ethics. Death with dignity?.
      Right to die–right or wrong?.
      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.
      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.
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • 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.
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      ,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      ,
      • Bahník Š
      • Vranka MA
      • Trefná K.
      What makes euthanasia justifiable? The role of symptoms' characteristics and interindividual differences.
      ,
      • Parpa E
      • Kostopoulou S
      • Tsilika E
      • et al.
      Psychometric properties of the greek version of the patient dignity inventory in advanced cancer patients.
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      ,
      • 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.
      ,
      • Chochinov HM
      • Kristjanson LJ
      • Hack TF
      • et al.
      Burden to others and the terminally ill.
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      ,
      • Houska A
      • Loučka M.
      Patients' autonomy at the end of life: a critical review.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      ,
      • Rowe Iii MJ
      Beliefs.
      • Drury B.
      The doctors of mercy.
      • Allmark P.
      Death with dignity.
      • Finlay IG.
      Quality of life to the end.
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      ,
      • Gentzler J.
      What is a death with dignity?.
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      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.
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • Parpa E
      • Kostopoulou S
      • Tsilika E
      • et al.
      Psychometric properties of the greek version of the patient dignity inventory in advanced cancer patients.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      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.
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • 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.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      ,
      • Allmark P.
      Death with dignity.
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      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.
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      ,
      • Allmark P.
      Death with dignity.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      self-image
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      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.
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • 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.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      Seventeen definitions contained aspects in the Individual Ring
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • 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.
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      ,
      • Parpa E
      • Kostopoulou S
      • Tsilika E
      • et al.
      Psychometric properties of the greek version of the patient dignity inventory in advanced cancer patients.
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      ,
      • Houska A
      • Loučka M.
      Patients' autonomy at the end of life: a critical review.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Rowe Iii MJ
      Beliefs.
      • Drury B.
      The doctors of mercy.
      • Allmark P.
      Death with dignity.
      • Finlay IG.
      Quality of life to the end.
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      ,
      • Gentzler J.
      What is a death with dignity?.
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      and involved autonomous function. These included loss of control,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • 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.
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • Houska A
      • Loučka M.
      Patients' autonomy at the end of life: a critical review.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Drury B.
      The doctors of mercy.
      ,
      • Allmark P.
      Death with dignity.
      ,
      • Gentzler J.
      What is a death with dignity?.
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      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.
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      and increased dependence on others.
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • 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.
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      ,
      • Allmark P.
      Death with dignity.
      ,
      • Gentzler J.
      What is a death with dignity?.
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      These considerations are exacerbated by symptoms,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      ,
      • Allmark P.
      Death with dignity.
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      futility of treatment,
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      treatment side-effects,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      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.
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      ,
      • Rowe Iii MJ
      Beliefs.
      ,
      • Allmark P.
      Death with dignity.
      ,
      • Finlay IG.
      Quality of life to the end.
      ,
      • Gentzler J.
      What is a death with dignity?.
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      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.
      Six definitions involved the Relational ring,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Parpa E
      • Kostopoulou S
      • Tsilika E
      • et al.
      Psychometric properties of the greek version of the patient dignity inventory in advanced cancer patients.
      ,
      • Chochinov HM
      • Kristjanson LJ
      • Hack TF
      • et al.
      Burden to others and the terminally ill.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      acknowledging the import of close social connections,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      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.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      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.
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      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.
      ,
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      ,
      • Bahník Š
      • Vranka MA
      • Trefná K.
      What makes euthanasia justifiable? The role of symptoms' characteristics and interindividual differences.
      ,
      • Allmark P.
      Death with dignity.
      Dignity was developed through life via interpersonal relationships,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      ,
      • Allmark P.
      Death with dignity.
      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.
      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.
      ,
      • Bahník Š
      • Vranka MA
      • Trefná K.
      What makes euthanasia justifiable? The role of symptoms' characteristics and interindividual differences.
      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.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      a developing sense of respect through interpersonal interactions,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      ,
      • Allmark P.
      Death with dignity.
      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.
      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.
      ,
      • Bahník Š
      • Vranka MA
      • Trefná K.
      What makes euthanasia justifiable? The role of symptoms' characteristics and interindividual differences.

      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.
      • 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.
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      • 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?.
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      • Buiting H
      • van Delden J
      • Onwuteaka-Philpsen B
      • et al.
      Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.
      • 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.
      • 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.
      • 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.
      • Rodríguez-Prat A
      • van Leeuwen E.
      Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies.
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      ,
      • Ganzini L
      • Goy ER
      • Dobscha SK.
      Why Oregon patients request assisted death: family members' views.
      ,
      • 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).
      ,
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      ,
      • van Tol D
      • Rietjens J
      • van der Heide A.
      Judgment of unbearable suffering and willingness to grant a euthanasia request by Dutch general practitioners.
      ,
      • 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.
      ,
      • Coyle N
      • Sculco L.
      Expressed desire for hastened death in seven patients living with advanced cancer: a phenomenologic inquiry.
      ,
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      • 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.
      • Karlsson M
      • Milberg A
      • Strang P.
      Dying cancer patients' own opinions on euthanasia: an expression of autonomy? A qualitative study.
      ,
      • Bolt EE
      • Pasman H
      • Deeg DJ
      • Onwuteaka-Philipsen BD
      From advance euthanasia directive to euthanasia: stable preference in older people?.
      ,
      • Chapple A
      • Ziebland S
      • McPherson A
      • Herxheimer A.
      What people close to death say about euthanasia and assisted suicide: a qualitative study.
      ,
      • Konishi E
      • Davis A.
      The right-to-die and the duty-to-die: Perceptions of nurses in the West and in Japan.
      • Wang L
      • Elliott M
      • Henson LJ
      • et al.
      Death with dignity in Washington and Oregon patients with amyotrophic lateral sclerosis.
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      • 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.
      • 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.
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      ,
      • Fischer S
      • Huber CA
      • Furter M
      • et al.
      Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians.
      ,
      • Al Rabadi L
      • LeBlanc M
      • Bucy T
      • et al.
      Trends in medical aid in dying in Oregon and Washington.
      ,
      • Kishore RR.
      Aruna Shanbaug and the right to die with dignity: the battle continues.
      ,
      • Ramsey C.
      The right to die: beyond academia.
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      • Gamester N
      • Van den Eynden B
      The relationship between palliative care and legalized euthanasia in Belgium.
      ,
      • Hiscox WE.
      Physician-assisted suicide in Oregon: The 'death with dignity' data.
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      ,
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      ,
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      ,
      • Rowe Iii MJ
      Beliefs.
      ,
      • Hale DB.
      A pretty pass: when is there a right to die?.
      • Fontalis A
      • Prousali E
      • Kulkarni K.
      Euthanasia and assisted dying: what is the current position and what are the key arguments informing the debate?.
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      ,
      • Freeman LM
      • Rose SL
      • Youngner SJ.
      Poverty: not a justification for banning physician-assisted death.
      • Kade WJ
      • Kade WJ.
      Death with dignity: a case study.
      • Roy DJ.
      Palliative care and euthanasia: a continuing need to think again.
      Unsurprisingly, attenuating these fears reduced WTHD.
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • 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.
      Gentzler
      • Gentzler J.
      What is a death with dignity?.
      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.
      ,
      • Coyle N
      • Sculco L.
      Expressed desire for hastened death in seven patients living with advanced cancer: a phenomenologic inquiry.
      ,
      • Heintz AP.
      Euthanasia–or, death on request.
      ,
      • Gandsman A.
      Paradox of choice and the illusion of autonomy: the construction of ethical subjects in right-to-die activism.
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      ,
      • Friend ML.
      Physician-assisted suicide: death with dignity?.
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      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.
      ,
      • 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.
      ,
      • Coyle N
      • Sculco L.
      Expressed desire for hastened death in seven patients living with advanced cancer: a phenomenologic inquiry.
      ,
      • Ramsey C.
      The right to die: beyond academia.
      ,
      • Heintz AP.
      Euthanasia–or, death on request.
      ,
      • Gandsman A.
      Paradox of choice and the illusion of autonomy: the construction of ethical subjects in right-to-die activism.
      ,
      • Granda-Cameron C
      • Houldin A.
      Concept analysis of good death in terminally ill patients.
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      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?.
      ,
      • Kishore RR.
      Aruna Shanbaug and the right to die with dignity: the battle continues.
      ,
      • Dyer C.
      Two men plead with judges to let doctors end their life legally.

      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.
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      ,
      • 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.
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      ,
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      ,
      • Drury B.
      The doctors of mercy.
      ,
      Right to die–right or wrong?.
      while eight opposed it.
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      ,
      • Drury B.
      The doctors of mercy.
      Three discussed its regulation.
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • 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.
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      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.
      ,
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      end suffering
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      and determine their own death.
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      ,
      • Drury B.
      The doctors of mercy.
      ,
      Right to die–right or wrong?.
      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.
      ,
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      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.
      subjective judgement of a patient's quality of life,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      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.
      ,
      • Drury B.
      The doctors of mercy.
      and pressure vulnerable patients to accept assisted dying.
      • Eliott JA
      • Olver IN.
      Dying cancer patients talk about euthanasia.
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.

      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.
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      • 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.
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Buiting H
      • van Delden J
      • Onwuteaka-Philpsen B
      • et al.
      Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      ,
      • Ganzini L
      • Goy ER
      • Dobscha SK.
      Why Oregon patients request assisted death: family members' views.
      ,
      • 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.
      ,
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      ,
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      ,
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      ,
      • Fischer S
      • Huber CA
      • Furter M
      • et al.
      Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians.
      ,
      • Ramsey C.
      The right to die: beyond academia.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      ,
      • Rowe Iii MJ
      Beliefs.
      ,
      • Drury B.
      The doctors of mercy.
      ,
      • McPherson T.
      My mum wanted assisted dying but we watched her die slowly and in pain.
      ,
      • Eastaugh A.
      Choosing to die.
      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.
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Buiting H
      • van Delden J
      • Onwuteaka-Philpsen B
      • et al.
      Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.
      ,
      • Ganzini L
      • Goy ER
      • Dobscha SK.
      Why Oregon patients request assisted death: family members' views.
      ,
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      ,
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      ,
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      ,
      • Fischer S
      • Huber CA
      • Furter M
      • et al.
      Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians.
      ,
      • Ramsey C.
      The right to die: beyond academia.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      ,
      • Rowe Iii MJ
      Beliefs.
      ,
      • Drury B.
      The doctors of mercy.
      respecting and fulfilling their autonomous desire for control
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Ganzini L
      • Goy ER
      • Dobscha SK.
      Why Oregon patients request assisted death: family members' views.
      ,
      • 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.
      ,
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      ,
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      ,
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Drury B.
      The doctors of mercy.
      and ending their suffering.
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      ,
      • Buiting H
      • van Delden J
      • Onwuteaka-Philpsen B
      • et al.
      Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.
      ,
      • Kouwenhoven PS
      • van Thiel GJ
      • Raijmakers NJ
      • et al.
      Euthanasia or physician-assisted suicide? A survey from the Netherlands.
      ,
      • Fischer S
      • Huber CA
      • Furter M
      • et al.
      Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians.
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      ,
      • Rowe Iii MJ
      Beliefs.
      Rodriquez
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      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.
      ,
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      ,
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      ,
      • Broom A.
      On euthanasia, resistance, and redemption: the moralities and politics of a hospice.
      ,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      ,
      • Ramsey C.
      The right to die: beyond academia.
      ,
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Raus K
      • Sterckx S.
      Euthanasia for mental suffering. New directions in the ethics of assisted suicide and euthanasia.
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      ,
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      ,
      • Drury B.
      The doctors of mercy.
      ,
      • Finlay IG.
      Quality of life to the end.
      ,
      • Dyer C.
      Dying woman loses her battle for assisted suicide.
      ,
      • Eastaugh A.
      Choosing to die.
      ,
      • Freeman LM
      • Rose SL
      • Youngner SJ.
      Poverty: not a justification for banning physician-assisted death.
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      ,
      • Fournier RR.
      Responses to life after death with dignity: the Oregon experience.
      These include guilt,
      • Finlay IG.
      Quality of life to the end.
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      grief
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      and emotional and moral distress
      • Mukhopadhyay S
      • Banerjee D.
      Physician assisted suicide in dementia: a critical review of global evidence and considerations from India.
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      ,
      • Ramsey C.
      The right to die: beyond academia.
      ,
      • Raus K
      • Sterckx S.
      Euthanasia for mental suffering. New directions in the ethics of assisted suicide and euthanasia.
      ,
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      ,
      • Drury B.
      The doctors of mercy.
      ,
      • Finlay IG.
      Quality of life to the end.
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      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.
      ,
      • Robinson V
      • Clarke J
      • George R.
      Euthanasia: a caricature of care, not a cure for suffering.
      ,
      • Ramsey C.
      The right to die: beyond academia.
      ,
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      ,
      • Drury B.
      The doctors of mercy.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      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?.
      and advocated instead for better palliative care
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      ,
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      ,
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      ,
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      ,
      • Eastaugh A.
      Choosing to die.
      and improved quality of life.
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      ,
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      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.
      ,
      • Feigin S
      • Owens RG
      • Goodyear-Smith F.
      Helping a loved one die: the act of assisted dying in New Zealand.
      ,
      • Konishi E
      • Davis A.
      The right-to-die and the duty-to-die: Perceptions of nurses in the West and in Japan.
      ,
      • Raus K
      • Sterckx S.
      Euthanasia for mental suffering. New directions in the ethics of assisted suicide and euthanasia.
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      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.
      ,
      • Freeman LM
      • Rose SL
      • Youngner SJ.
      Poverty: not a justification for banning physician-assisted death.
      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.
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      along with vagaries surrounding prognostication,
      • Raus K
      • Sterckx S.
      Euthanasia for mental suffering. New directions in the ethics of assisted suicide and euthanasia.
      the subjectivity of quality of life determinations
      • Rodriquez E.
      The arguments for euthanasia and physician-assisted suicide: ethical reflection.
      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.
      ,
      • Konishi E
      • Davis A.
      The right-to-die and the duty-to-die: Perceptions of nurses in the West and in Japan.
      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.
      ,
      • Florijn BW.
      From reciprocity to autonomy in physician-assisted death: an ethical analysis of the dutch supreme court ruling in the albert heringa case.
      ,
      • Hale DB.
      A pretty pass: when is there a right to die?.
      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.
      ,
      • Hale DB.
      A pretty pass: when is there a right to die?.
      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.
      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.
      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.
      ,
      • Hale DB.
      A pretty pass: when is there a right to die?.
      ,
      • Dyer C.
      Dying woman loses her battle for assisted suicide.
      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.
      ,
      • 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.
      ,
      • Bailey F.
      I am not afraid of dying. I just don't want to be there when it happens.
      ,
      • Reagan P
      • Hurst R
      • Cook L
      • et al.
      Physician-assisted death: dying with dignity?.
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      ,
      • Broom A.
      On euthanasia, resistance, and redemption: the moralities and politics of a hospice.
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      ,
      • Comby M
      • Filbet M.
      The demand for euthanasia in palliative care units: a prospective study in seven units of the 'Rhone-Alpes' region.
      ,
      • 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.
      ,
      • Chapple A
      • Ziebland S
      • McPherson A
      • Herxheimer A.
      What people close to death say about euthanasia and assisted suicide: a qualitative study.
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      ,
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      ,
      • Ganzini L
      • Back A.
      From the USA: Understanding requests for physician-assisted death.
      • Ramsey C.
      The right to die: beyond academia.
      • Gómez-Vírseda C
      • Gastmans C.
      Euthanasia in persons with advanced dementia: a dignity-enhancing care approach.
      ,
      • Reid T.
      Reflections from a provider of medical assistance in dying.
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      ,
      • Friend ML.
      Physician-assisted suicide: death with dignity?.
      ,
      • Abrahm JL.
      Patient and family requests for hastened death.
      ,
      • Salladay SA.
      Christian ethics. Death with dignity?.
      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.
      ,
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      ,
      • Barutta J
      • Vollmann J.
      Physician-assisted death with limited access to palliative care.
      ,
      • Freeman LM
      • Rose SL
      • Youngner SJ.
      Poverty: not a justification for banning physician-assisted death.
      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.
      ,
      • Coyle N
      • Sculco L.
      Expressed desire for hastened death in seven patients living with advanced cancer: a phenomenologic inquiry.
      ,
      • Ganzini L
      • Dobscha SK
      • Heintz RT
      • Press N
      Oregon physicians' perceptions of patients who request assisted suicide and their families.
      ,
      • Drum CE
      • White G
      • Taitano G
      • Horner-Johnson W.
      The oregon death with dignity act: results of a literature review and naturalistic inquiry.
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      ,
      • Finlay IG.
      Quality of life to the end.
      ,
      • Roy DJ.
      Palliative care and euthanasia: a continuing need to think again.
      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.
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      ,
      • Broom A.
      On euthanasia, resistance, and redemption: the moralities and politics of a hospice.
      ,
      • 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.
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      ,
      • Gentzler J.
      What is a death with dignity?.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      psychological,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      and existential issues,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      ,
      • 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.
      ,
      • Wilson KG
      • Chochinov HM
      • McPherson CJ
      • et al.
      Desire for euthanasia or physician-assisted suicide in palliative cancer care.
      ,
      • Wilson KG
      • Scott JF
      • Graham ID
      • et al.
      Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.
      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.
      ,
      • Ganzini L
      • Nelson HD
      • Schmidt TA
      • et al.
      Physicians' experiences with the oregon death with dignity act.
      ,
      • Broom A.
      On euthanasia, resistance, and redemption: the moralities and politics of a hospice.
      ,
      • 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.
      ,
      • Duckett S
      Pathos, death talk and palliative care in the assisted dying debate in Victoria, Australia.
      ,
      • Gentzler J.
      What is a death with dignity?.
      ,
      • Mentzelopoulos SD
      • Haywood K
      • Cariou A
      • Mantzanas M
      • Bossaert L.
      Evolution of medical ethics in resuscitation and end of life.
      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.
      ,
      • Goligher EC
      • Wesley Ely E
      • Sulmasy DP
      • et al.
      Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethical issues.
      ,
      • Simpson E.
      Harms to dignity, bioethics, and the scope of biolaw.
      ,
      • Stephenson J.
      Assisted dying: a palliative care physician's view.
      ,
      • Finlay IG.
      Quality of life to the end.