Suicide among the elderly in France and Switzerland: What does the societal context tell us about the place of relatives?

Based on a comparison of accounts by relatives of elderly people who died by suicide in France and by assisted suicide in Switzerland, this article analyzes the place of family members and their interpretations of the suicide of their elderly relative. It highlights the way the societal and legal context influences the collection of data, the feelings of relatives and their interpretations. While in France, relatives try to avoid the risk of the family being stigmatized and try to retrospectively reconstruct the reasons for the suicide, the institutionalization of suicide in Switzerland means that the reasons for suicide are formulated in advance.

Assistance in dying: Conditions for international comparison.

This special issue of Death Studies interrogates conditions for conducting international comparisons of assistance in dying regimes, and of related discourses and practices. To do so, it provides comparative social sciences and humanities perspectives on assistance in dying. In this editorial introduction, we first trace the origin of this special issue to the symposium held in 2018 in Lausanne, Switzerland. We then offer a short exploration of how assistance in dying regimes have been compared in the literature. Finally, we identify key conditions for conducting international comparisons of assistance in dying based on the articles presented in this issue of Death Studies.

Swiss Families' Experiences of Interactions with Providers during Assisted Suicide: A Secondary Data Analysis of an Interview Study.

Context: Families are known to be involved in assisted dying and their involvement can be influenced by many factors. Objectives: To explore how Swiss families interact with health care professionals and right-to-die associations regarding assisted suicide and their choices around disclosure. Methods: A secondary data analysis on a cross-sectional qualitative interview study conducted in the Italian- and French-speaking parts of Switzerland was conducted. Interviews with 28 bereaved family members were analyzed using framework analysis. Results: Two main themes were identified: (1) Interactions with physicians and right-to-die associations. (2) Choices about disclosing their experiences. In general, families believed that assisted suicide is a private matter, to be pursued mainly outside the medical field and involved physicians only when necessary. Families appeared to deliberately limit interaction with physicians and to be more comfortable interacting with the right-to-die associations. Some participants presumed a clear choice between assisted suicide or palliative care. Disclosing to others the decision, and preparation of assisted suicide emerged to be an important emotional burden for families. Some family members preferred to restrict disclosure before and after assisted suicide, by sometimes not informing other family members until the final days. Conclusions: In Switzerland, there is limited interaction between families and health care professionals concerning assisted suicide decisions, whereas families reported more open interactions with right-to-die associations. It is recommended that the needs of families should be reflected in health policies, taking into consideration the different contexts where assisted dying is permitted.

Family Caregivers' Reflections on Experiences of Assisted Suicide in Switzerland: A Qualitative Interview Study.

CONTEXT: Thousands of family members worldwide are annually involved in assisted dying. Family participation in assisted dying has rarely been investigated and families' needs typically are not considered in assisted dying legislation and clinical guidelines. OBJECTIVES: To explore family caregivers' reflections on experiences of assisted suicide in Switzerland. METHODS: A cross-sectional qualitative interview study conducted in the Italian- and French-speaking regions of Switzerland. Interpretation and analysis were performed using qualitative content analysis. RESULTS: Twenty-eight close relatives and family carers of 18 patients who died by assisted suicide in Switzerland were interviewed. Family members perceived their involvement in assisted suicide as characterized by five phases; 1) contemplation, 2) gaining acceptance, 3) gaining permission, 4) organization, and 5) aftermath. Families can participate in these phases at diverse levels and with varying degrees of involvement. Important triggers for families and patients for transition between phases include patients' experiences of their life-threatening illnesses and related treatments, their increasing awareness of approaching death, and family member recognition of their loved one's unbearable suffering. Participating in assisted suicide created further demanding tasks for families in addition to their role of caregivers. CONCLUSION: Families appeared to be involved in the preparation of assisted suicide along with patients, irrespective of their personal values regarding assisted dying. Support for family members is essential if they are involved in tasks preparatory to assisted suicide. Clinical guidelines and policies concerning assisted dying should acknowledge and address family needs.

Exploring the experiences of bereaved families involved in assisted suicide in Southern Switzerland: a qualitative study.

BACKGROUND: In Switzerland, helping with assisted suicide under certain conditions is not prosecuted. With approximately 300 cases annually, this leaves behind a large group of bereaved people where its consequences are mostly unknown. The study aimed to explore family involvement in decision making prior to assisted suicide, and to examine their ways of coping during the bereavement period. METHODS: A qualitative interview study used the principles of Grounded Theory analysis. Eleven relatives of eight patients, who died in Southern Switzerland after assisted suicide, participated in semistructured interviews. RESULTS: The large majority of family members faced moral dilemmas during the decision-making phase. Their respect for patient's autonomy was a key justification to resolve dilemmas. Two types of involvement were identified: categorised as 'passive' when the decision making was located with the patient, and 'active' when assisted suicide was proposed by the family member and/or the relative was involved in some way. The relatives reported feelings of isolation during and after assisted suicide. Family members reported fear of social stigma and did not openly disclose assisted suicide as the cause of death. None of those interviewed received formal psychological support. CONCLUSIONS: Bereaved families express moral dilemmas, feelings of isolation and secrecy in the management of assisted suicide in Southern Switzerland. These features seem underestimated and not sufficiently recognised by the healthcare professionals. Management of assisted suicide requests should include consideration of family members' needs, in addition to those of the patient.

Views of healthcare professionals dealing with legal termination of pregnancy up to 12 WA in French-speaking Switzerland.

BACKGROUND: In 2002, by popular vote, Swiss citizens accepted to legalise termination of pregnancy (TOP), up to the 12th week of amenorrhoea (WA). As a result, the cantons formulated rules of application. In 2002, medical TOP was authorised. Health institutions then had to modify their procedures and practices. QUESTIONS UNDER STUDY/PRINCIPLES: What are the views of healthcare professionals on the modifications of procedures and practices implemented in French-speaking Switzerland? METHODS: Qualitative method: in-depth interviews with 77 healthcare professionals, including doctors, nurses and midwives, and sexual and reproductive health social workers. Voluntary participation. Thematic analysis with content analysis software. RESULTS: Most professionals have a balanced point of view on their practices. There is no point of view specific to each different category of professionals interviewed. They are unanimous on the elimination of the need for a second opinion. The points of view diverge on the usefulness of imposed waiting time to think before TOP, minors' access to TOP without parental consent, access to medical TOP and the right to refuse to practice TOP for personal reasons in public hospitals. CONCLUSIONS: The professionals do not question women's right to have TOP up to 12 WA, but they do diverge over procedures and practices. Institutional and cantonal cultures are probably behind these differences.

Clinical course in women undergoing termination of pregnancy within the legal time limit in French-speaking Switzerland.

BACKGROUND: In 2002, Swiss citizens voted to accept new laws legalising the termination of pregnancy (TOP) up to 12th week of pregnancy. As a result the cantons formulated rules of implementation. Health institutions then had to modify their procedures and practices. QUESTIONS UNDER STUDY/PRINCIPLES: One of the objectives of these changes was to simplify the clinical course for women who decide to terminate a pregnancy. Have the various health institutions in French-speaking Switzerland attained this goal? Are there differences between cantons? Are there any other differences, and if so, which ones? METHODS: Comparative study of cantonal rules of implementation. Study by questionnaire of what happened to 281 women having undergone a TOP in French-speaking Switzerland. Quantitative and qualitative method. RESULTS: The comparative legal study of the six cantonal rules of implementation showed differences between cantons. The clinical course for women are defined by four quantifiable facts: 1) the number of days delay between the woman's decision (first step) and TOP; 2) the number of appointments attended before TOP; 3) the method of TOP; 4) the cost of TOP. On average, the waiting time was 12 days and the number of appointments was 3. The average cost of TOP was 1360 CHF. The differences, sometimes quite large, are explained by the size of the institutions (large university hospitals; average-sized, non-university hospitals; private doctors' offices). CONCLUSIONS: The cantonal rules of implementation and the size of the health care institutions play an important role in these courses for women in French-speaking Switzerland.

[Accepting chemotherapy at the age of 70 and over: between autonomy and ageing]. / Accepter une chimiothérapie à 70 ans et plus: entre autonomie et entrée dans la vieillesse.

This study is based on the interview of 21 subjects, aged 70 years and over, attending an oncology centre. At the end of their treatment, we have explored the processes of patient's choice, including goals, resources and constraints. The main variables influencing the acceptance of chemotherapy are full awareness of one's clinical condition, irrespective of whether a cure is possible or not, self perceived state of health, and lastly life expectancy. Age itself initially does not appear to be a limiting factor. Every effort should be made to tailor communication to individual needs, not least because of a link between learned and perceived treatment adverse effects. We found that symptoms, especially fatigue, hamper routine activities, leading to social withdrawal. Gradually the manifestations of the disease itself and of its treatment, combined with age, reveal both personal vulnerability and the role of support networks.

[Management and quality: in search of nursing]. / Cadres et qualité: à la recherche des soins infirmiers.

Quality management involves everyone in the hospital to a different degree. The head-nurses are key elements for the realization of these programs. Throughout this discussion regarding management, this article explores the links between quality management and nursing. The interviews conducted show that management has over-invested in quality. Therefore it will respond to problems concerning work organization and will also allow a professional acknowledgement. The analysis confirms that the quality values come before that of a pragmatic conception of health care based on a disjunctive viewpoint, both linear and timeless. Furthermore, because nursing is not considered as a discipline, quality healthcare remains undefined. The recommendations focus on the manager's role and particularity on the definition of the principal problems of different services.

[Palliative care network and the elderly: what autonomy do they have?]. / Soins palliatifs en réseau et patients âgés: quelle autonomie pour eux?

Several Swiss institutions of a socio-sanitary region have put together a network with the view of assuring efficient palliative care. A research was conducted in partnership with four health-care establishments in order to verify if the concept of autonomy conceived by professionals corresponded to the patients' needs. Semi-directive interviews were conducted, along with questionnaires. The analysis showed a considerable disparity between palliative philosophy and the real needs of elderly patients. The aging process experienced by the people interviewed was synonymous with illness, loss, suffering and quality of life are associated with youth. The dimension of the projects and partnerships is difficult for them to imagine.