Implications for practice and research

• Different levels of advocating for assisted dying between people with dementia and health professionals may mean professionals need more confidence, support and awareness to have these conversations.

• Further qualitative research is needed to explore in more detail the views carers and people with dementia have about assisted dying.

Context

There is growing attention on assisted suicide and dementia internationally.1 At the end of life we see people with dementia lose their ability to make their own decisions and maintain control. This is often epitomised by dignity which was once intrinsic and controlled by the individual and later becomes extrinsic and maintained by those around them. Assisted dying in a way empowers the person with dementia to retain their control and choice with decisions.

Findings

Eighteen studies were included, most of which were from the USA (eight), followed by the Netherlands (five). The public were most in favour of euthanasia and PAS for people with severe dementia, whereas carers and people with dementia were more supportive of PAS in the early stages of dementia. Physicians and nurses were most resistant to assisted dying in general, being more favourable in mild dementia; however, there may be a trend to be more supportive for euthanasia in advanced dementia when advanced euthanasia directives are written. Several factors were found to be associated with attitudes towards assisted dying including age, ethnicity, gender and religion.

Commentary

This is the first review that has explored attitudes towards assisted dying specifically in relation to dementia. This narrow overview of studies comes at a point at which assisted dying has received heightened media attention in recent years.

The review demonstrates a division of opinion across different populations as well as severity of dementia. Support in particular from professionals who would need to perform assisted dying is greater in mild dementia as this is when capacity is less of an issue. However, Bolt et al3 demonstrated that a small number of Dutch physicians find it conceivable they would assist death with a person with dementia.

The study suggests healthcare professionals should be mindful of the more supportive views of people with dementia and carers towards assisted dying when discussing end-of-life care options. However, extreme caution must be taken. As demonstrated in this study, not all will have such a supportive view and opinions will vary. As shown in previous reviews of attitudes towards end-of-life care in dementia, carers’ views in particular may change and span a spectrum of beliefs.4 Caution would also need to be taken of any other comorbid psychological disorders such as depression, which may compound an individual's desire for assisted dying.5

The authors rightly acknowledge that there are several limitations with the studies included in this review, including poor design of survey methodologies leading to biased responses and a lack of standardised measures. They highlight the need for research to explore the explanations behind the attitudes reported.

This information is important in informing on-going debate internationally about the role of assisted dying in dementia and the attitudes of those most affected about this sensitive topic of debate.