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[...]there is no evidence that pain generates unique signs and behaviours. The use of a tool to document signs and behaviours of distress empowers carers to know and tell others that the change in behaviour is distress and not the underlying condition.5 It is freely available (www.disdat.co.uk) and used by many intellectual disability teams and some dementia teams. 10.1093/pm/pnx268 29136228 4 Erdal A Flo E Aarsland D. Tolerability of buprenorphine transdermal system in nursing home patients with advanced dementia: a randomized, placebo-controlled trial (DEP.PAIN.DEM).

Objective: There is a concern that pain is under-recognized in dementia. However, there may be other causes of distress. We wished to evaluate the utility of a distress tool and a pain tool. Methods: Nursing home residents with advanced dementia were observed using pain (Pain Assessment in Advanced Dementia scale (PAINAD)) and distress (Disability Distress Assessment Tool (DisDAT)) assessment tools. Those in pain were treated. Reassessment occurred at one and three months. Results: From 79 participants, 13 were assessed as being in pain. Psychosocial factors explained the behaviour of a false positive group. Both tools showed a significant decrease in pain following intervention (p = 0.008). Behaviours were similar in both groups. Conclusions: Both tools are useful. However, the pain tool also picks up distress, which is not caused by pain. It could potentially lead to false ascriptions of pain. The distress tool picks up a broader array of signs, which may be useful both in practice and in research.

ObjectivesAssisted dying has been legally available in Oregon in the USA for 25 years, since when official reports have been published each year detailing the number of people who have used this option as well as sociodemographic and information about the process. The aim of this study was to examine changes over time in these data.MethodsWe collated and reviewed data on 2454 assisted deaths included in annual reports on assisted deaths published by the Oregon Health Authority from 1998 to 2022. Descriptive statistics were used to describe time trends.ResultsThe number of assisted deaths in Oregon increased from 16 in 1998 to 278 in 2022. Over this time, patients’ health funding status changed from predominantly private (65%) to predominantly government support (79.5%), and there was an increase in patients feeling a burden and describing financial concerns as reasons for choosing an assisted death. There has been a reduction in the length of the physician–patient relationship from 18 weeks in 2010 to 5 weeks in 2022, and the proportion referred for psychiatric assessment remains low (1%). Data are frequently missing, particularly around complications.ConclusionsThe number and characteristics of people accessing assisted deaths, and the process, have changed since data collection started in 1998. Prospective studies are needed to examine the relationship between socioeconomic factors and the desire for an assisted death in Oregon.

claudregnard@stoswaldsuk.org Hurley and colleagues’ promotion of the proposed assisted dying bill in England and Wales ignores the obstacles.1 In last year’s BMA survey, a majority of doctors were unwilling to prescribe the necessary drugs.2 Will we end up like Oregon, where a tiny proportion of doctors prescribe (one writing 31 prescriptions in 2020)?3 Every legislature has shortened or removed cooling off periods and expanded their criteria beyond a six month prognosis, some allowing or currently discussing assisted deaths in people with mental illness, learning disability, and autism and in children. Updated 14 Sep 2021. https://www.bma.org.uk/advice-and-support/ethics/end-of-life/physician-assisted-dying/physician-assisted-dying-survey 3 Oregon Health Authority. Oregon Death with Dignity Act annual reports. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ar-index.aspx 4 Willis D George R. Conscientious objection and physician-assisted suicide: a viable option in the UK?

Assisted Suicide (AS) inspires strong opinions on all sides of the debate. There is no consensus around the terminology. When medical policy on PAS (physician assisted suicide) is being considered in several countries, as it is at present, there is a need for high quality evidenceA Medline search for Assisted Suicide brings up 5,550 results, but a large proportion of these are com- mentaries, opinions, case reports and discussion. There are relatively few objective studies on its practice that have been published in peer reviewed journals. For example, there are very few studies published on complication rates of the drugs used in AS. There is little comparative data on the quality of life in AS and non AS deaths. There are several official data sources in areas where AS is legal but the extent and quality of the data collected varies considerably with much missing data. In Oregon, data regarding complications in AS cases is missing in 63% of cases. All areas where AS is legal, use retrospective monitor- ing systems. It can be difficult to gather accurate information. The lack of well-conducted, high quality objective research is a challenge for all those involved in the AS debate.uma.nath@btinternet.com

ObjectivesMost clinical teams and organisations have not openly or formally discussed how they would react if physician-assisted suicide were to be legalised. This paper aims to discuss some of the potential challenges of introducing ‘assisted dying’ into medical care and produces a table of questions and considerations in light of such evidence so as to promote necessary discussion.MethodsAn analysis of recent quantitative and qualitative studies from jurisdictions where ‘assisted dying’ is practised was conducted, with particular attention paid to studies which focus on the impact of legalising ‘assisted dying’ on clinical care.Results‘Assisted dying’ can have a significant impact on clinical practice by complicating patient care and increasing clinician workload, potentially causing stress on patient care.ConclusionsIf physician-assisted suicide was to be legalised as part of existing healthcare, there are many questions that healthcare organisations must consider. Such considerations are tabulated in order to encourage awareness and discussion on the topic.

[...]behavioural disturbances can have many different causes; causes such as constipation will be worsened by opioid analgesia. [...]there is no convincing evidence that pain produces unique signs and behaviours. 2 Thirdly, pain tools in people with severe communication difficulties have poor validity. 3 Tools such as PAINAD detect causes of distress that are not pain, 4 creating mistakenly high estimates for the prevalence of pain in dementia.

ReSPECT is the final product of a personal process with several stages: respecting the opportunity to reach shared understanding and discuss realistic choices for future care eases uncertainty; listening shows respect by working at the pace and ability of the patient and those close to them; and shared decision making shows respect for the patient's wishes, preferences, beliefs, and values in accordance with capacity legislation.

ObjectivesOfficial data reports from countries where assisted suicide and euthanasia is legal are an important resource for discerning participation rates, patient safety and transparency in the way that assisted dying is legal. We aimed to identify what information is published in official data reports on assisted suicide and euthanasia across jurisdictions.MethodsWe searched for official data reports from every jurisdiction where assisted suicide or euthanasia is legal. Searches were conducted on these countries’ official health authority websites as well as on mainstream search engines. The data measures included within each report were described in four categories: participation data, patient characteristics, clinician characteristics, and drugs and dying process.ResultsWe found that 16 jurisdictions where assisted suicide or euthanasia is currently legal regularly publish data reports regarding its practice. The information included within these official reports varies greatly, with few measures published across all or most jurisdictions.ConclusionsDifferences in the kinds of information published within official reports on assisted suicide and euthanasia makes comparing the practice of assisted suicide and euthanasia across jurisdictions challenging. Many jurisdictions fail to report data measures, which could be valuable to the understanding of assisted suicide and euthanasia practices within that country. Improving data reporting across jurisdictions where assisted suicide and euthanasia is legal, for example, through establishing minimum requirements for data collection and reporting, is an important step towards ensuring patient safety and the transparent practice of assisted suicide and euthanasia.