Today, almost two thirds of deaths in Switzerland are foreseeable due to old age or terminal illness. This means that difficult end-of-life decision have to be made. “We wanted to examine how the cultural differences inherent to a multilingual country like ours influence end-of-life decisions, in spite of a common federal legislative framework,” explains Samia Hurst, Director of the Institute for History, Ethics and Humanities at the Faculty of Medicine of University of Geneva.
In their study, researchers from the University of Zurich and the University of Geneva noticed significant differences between regions. However, these differences were not always as pronounced as those observed between the regions and the countries with which they share a language.
Assisted suicide only marginal
Across all regions, in more than three quarters of cases deaths were preceded by at least one end-of-life decision, mainly decisions to administer or withhold life-sustaining treatment (70.0% in German-speaking Switzerland, 59.8% in French-speaking Switzerland, and 57.4% in Italian-speaking Switzerland).
The use of assisted suicide remains marginal, with only about 1.5% of all expected deaths in French and German-speaking Switzerland, and no case reported in Italian-speaking Switzerland. Swiss law allows assisted suicide, whereby the person who wants to die is provided with a lethal dose of medication by a physician, but has to administer the medication themselves. Active euthanasia, however, i.e. where someone else administers the legal dose, is illegal.
Patients less involved in Ticino
The involvement of patients in the decision-making process was significantly lower in Ticino than in the rest of the country. “This result cannot be explained by objective clinical differences,” says Matthias Bopp. The researchers suspect that when it comes to making end-of-life decisions, a more family-based culture is prevalent in Ticino.
Similar studies have been conducted in Italy and France, allowing international comparison on a linguistic basis. “Even if we don’t die the same way in all regions of our country, our approaches are still more similar in relation to each other than that of our neighbors. In some respects, French-speaking Switzerland thus resembles German-speaking Switzerland more than it resembles France, which is in line with the increased role of patient autonomy in Switzerland,” says Samia Hurst. Nevertheless, the differences observed between Swiss regions are similar to the differences noted between Italy and France, which also suggests cultural peculiarities associated with language. Unfortunately, neither Germany nor Austria have carried out such studies, an important limiting factor in this transnational analysis.
Promoting advance directives
More and more people in Switzerland are aware of the possibility of drafting advance directives detailing their end-of-life choices. However, few people actually write them. “It is important for each of us to reflect on what our priorities will be at the end of life. What do we hope for? What do we fear? What is most important to us? Furthermore, people should, if possible, have this discussion with a trusted health professional. This will help them to correctly understand the medical and technological aspects of their decisions as well as their consequences,” emphasizes Matthias Bopp.
The project was a part of the National Research Program End of Life (NFP 67) funded by the Swiss National Science Foundation (SNSF).
Samia A. Hurst, Ueli Zellweger, Georg Bosshard, Matthias Bopp: «Medical end-of-life practices in Swiss cultural regions: a death certificate study». BMC Medicine. 20. April 2018, DOI: 10.1186/s12916-018-1043-5
9,000 physicians surveyed
To investigate the medical decisions at the end of life, the researchers randomly picked out 9'000 death cases and sent an anonymous questionnaire to the physicians who treated the cases – 4,998 in German-speaking Switzerland, 2,965 in French-speaking Switzerland, and 1,000 in Ticino. The response rate ranged from nearly 52% in French-speaking Switzerland to 63% for German-speaking physicians. “The considerable response rate strongly suggests that the participating physicians appreciated our efforts to ensure the strictest anonymity of the respondents,” stresses Matthias Bopp from the Epidemiology, Biostatistics and Prevention Institute at the University of Zurich.