Image copyright AFP Image caption Belgium is the only country that permits euthanasia without age restrictions 
 
 A terminally ill 17-year-old has become the first minor to be helped to die in Belgium since age restrictions on euthanasia requests were removed two years ago, officials say. 
 
 The head of the federal euthanasia commission said the teenager was "suffering unbearable physical pain". 
 
 Belgium is the only country that allows minors of any age to choose euthanasia. 
 
 They must have rational decision-making capacity and be in the final stages of a terminal illness. 
 
 The parents of those under 18 must also give their consent. 
 
 Euthanasia commission head Wim Distelmans said the teenager was "nearly 18". He said doctors used "palliative sedation", which involves putting patients into an induced coma, as part of the process, 
 
 Assisted dying around the world 
 
 Belgian Paralympian 'not ready' for euthanasia 
 
 "Fortunately there are very few children who are considered [for euthanasia] but that does not mean we should refuse them the right to a dignified death," he told the Het Nieuwsblad newspaper. 
 
 Mr Distelmans told Reuters news agency the case had been reported to his committee by a local doctor last week. 
 
 The case involved a Dutch-speaking patient, reports public broadcaster RTBF. 
 
 The Netherlands also allows euthanasia for minors, but they must be aged over 12 years old. 
 
 Belgium lifted the age restrictions in 2014. The law passed by parliament said the child would have to be terminally ill, face "unbearable physical suffering" and make repeated requests to die before euthanasia is considered. 
 
 Image copyright AFP Image caption Belgian Paralympian Marieke Vervoort, who suffers from an incurable degenerative muscle disease, says she will choose euthanasia, but not yet. 
 
 Many people, including church leaders and some paediatricians, questioned whether children would be able to make such a difficult choice. 
 
 Senator Jean-Jacques De Gucht said he was proud the legislation had passed. 
 
 He said having the possibility to ask about euthanasia "makes a big difference to many people". 
 
 Where is assisted dying permitted? 
 
 The Netherlands, Belgium and Luxembourg permit euthanasia and assisted suicide 
 
 Switzerland permits assisted suicide if the person assisting acts unselfishly 
 
 Colombia permits euthanasia 
 
 California last year joined the US states of Oregon, Washington, Vermont and Montana in permitting assisted dying 
 
 Canada passed laws allowing doctor-assisted dying in June of this year 
 
 How old must the patient be? 
 
 Only the Netherlands and Belgium permit euthanasia for patients under the age of 18. 
 
 In the Netherlands, a competent patient between the ages of 16 and 18 may request euthanasia or assisted suicide. The parent or guardian does not have a veto, but must be consulted. Competent patients aged between 12 and 16 may also qualify, but only if their parent or guardian consents. 
 
 In Belgium, a competent patient under the age of 18 may request euthanasia with parental consent. Additional scrutiny of the child's competence is required, and suffering based on a psychiatric disorder is excluded. 
 
 How many people take this option? 
 
 The rate of euthanasia in the Netherlands has remained fairly stable at 2.8% of all deaths (in 2010), according to Penney Lewis, Professor of Law at King's College London. 
 
 The most recent survey of doctors in the UK was in 2007-08. The rate of euthanasia was reported to be 0.21% of all deaths, and a similar rate has been reported in France (in 2009), even though euthanasia remains illegal in both countries. 
 
 In contrast, research carried out in Flanders, Belgium found the rate prior to legalisation was unclear, with separate surveys reporting rates of 0.3% of all deaths in the region (in 2001-02) and 1.1% (in 1998). The rate has risen steadily since legalisation in 2002 to 4.6% of all deaths in the most recent survey in 2013. 
 
 What do the different terms mean? 
 
 Euthanasia is an intervention undertaken with the intention of ending a life to relieve suffering, for example a lethal injection administered by a doctor 
 
 Assisted suicide is any act that intentionally helps another person kill themselves, for example by providing them with the means to do so, most commonly by prescribing a lethal medication 
 
 Assisted dying is usually used in the US and the UK to mean assisted suicide for the terminally ill only, as for example in the Assisted Dying Bills recently debated in the UK ||||| The head of Belgium's federal euthanasia commission gave no details of the child beyond saying the patient was an exceptional case of a young person with a terminal illness, the "Het Nieuwsblad" newspaper reported. 
 
 Belgium became the first country in 2014 to drop all age restrictions on euthanasia 
 
 "Fortunately there are very few children who are considered (for euthanasia), but that does not mean we should refuse them the right to a dignified death," Wim Distelmans told the newspaper. 
 
 Belgium amended its euthanasia law in 2014 - following heated debate - opening the possibility of euthanasia to children "in a hopeless medical situation of constant and unbearable suffering that cannot be eased and which will cause death in the short term." 
 
 The Netherlands allows euthanasia for people as young as 12. It is also legal in Luxembourg. 
 
 Belgium first legalized mercy killings in 2002. Between 2003 and 2013, the number of patients being euthanized in Belgium rose nearly eight-fold to a total number of 8,752 cases, according to the national euthanasia control committee. 
 
 Any request for euthanasia must be made by the child, approved by a panel of physicians, an independent psychiatrist or psychologist and have parental consent. But the case files - which document the patient's condition and official deliberations leading to the decision - often remain sealed. 
 
 jar/sms (Reuters, AFP) ||||| BRUSSELS (Reuters) - A 17-year-old has committed doctor-assisted suicide in Belgium, the first minor to do so under rules adopted in 2014 allowing euthanasia for people of all ages, the head of the national committee for euthanasia said on Saturday. 
 
 Wim Distelmans, who chairs Belgium's Federal Control and Evaluation Committee on Euthanasia, told Reuters that the minor was 17 and that a local doctor had reported the case to his committee last week, but he gave no other details. 
 
 Belgium legalized euthanasia in 2002, and two years ago amended the rules to permit doctor-assisted death for minors in a hopeless medical situation and with their explicit consent. 
 
 It is the only country in the world that allows euthanasia for minors of all ages. In the neighboring Netherlands the practice is legal for children aged 12 or over. 
 
 Distelmans said in an emailed statement that the Belgian law defines euthanasia very strictly. Minors must be conscious and able to make rational decisions when they request assisted death. Psychologists or psychiatrists must be consulted and the parents must give their permission. 
 
 To undergo euthanasia, the minor must also be in a "terminal medical situation with constant and unbearable physical pain which cannot be assuaged and that will cause death in the short term", the law says. 
 
 In the ten years to 2013, the number of euthanasia cases in Belgium rose from about 1,000 to 8,752, according to official records. 
 
 Euthanasia laws vary by country. Laws in Belgium, the Netherlands, Colombia and Luxemburg allow mercy deaths for adults, which usually means a doctor administering lethal doses of barbiturates. 
 
 In Switzerland, Germany, Japan and Canada, doctor-assisted suicide, where people take the final action themselves, is legal. ||||| The Netherlands and Belgium became the first countries to legalise euthanasia in 2002 (AFP Photo/Etienne Ansotte) 
 
 Brussels (AFP) - A terminally ill 17-year-old has become the first minor to be euthanised in Belgium since age restrictions on such mercy killings in the country were lifted in 2014, it was learned Saturday. 
 
 "The euthanasia has taken place," Jacqueline Herremans, a member of Belgium's federal euthanasia commission, told AFP. 
 
 She added that the assisted death had taken place according to Belgian law. 
 
 Wim Distelmans, head of the euthanasia commission, gave no details of the minor involved beyond saying it was an exceptional case of a child with a terminal illness, the Het Nieuwsblad newspaper reported. 
 
 VRT public television said the incident involved an adolescent who was about to turn 18. 
 
 "Fortunately, there are very few children who are considered (for euthanasia) but that does not mean we should refuse them the right to a dignified death," Distelmans told the newspaper. 
 
 Since 2014, when its euthanasia legislation was amended, Belgium has been the only country in the world that allows terminally-ill children of any age to choose to end their suffering -- as long as they are conscious and capable of making rational decisions. 
 
 The Netherlands also allows mercy killings for children, but only for those aged over 12. 
 
 - 'Very controlled' - 
 
 The Belgian amendment, which was passed after heated debate -- notably over the meaning of a "capacity of discernment" -- offers the possibility of euthanasia to children "in a hopeless medical situation of constant and unbearable suffering that cannot be eased and which will cause death in the short term". 
 
 Any request for euthanasia must be made by the minor, be studied by a team of doctors and an independent psychiatrist or psychologist, and have parental consent. 
 
 When amending the law, Belgian legislators had decided not to include psychological suffering in the list of factors determining whether euthanasia may be allowed for minors, though it is admissable for adults. 
 
 The 2014 vote was passed by 86 lawmakers in favour and a 44 against, in the traditionally Catholic nation. 
 
 A poll which was taken a few months before the final parliamentary vote indicated that three-quarters of Belgians were in favour of extending euthanasia to minors. 
 
 Since the law was changed, there have been other euthanasia requests from minors but none had previously been granted, said Herremans. 
 
 The whole process is "very controlled" and "often very long" and particularly difficult when it concerns a minor, she added. 
 
 Altogether over 2,000 mercy killings were declared in Belgium last year, a record number since the practice was made legal in 2002. 
 
 Last weekend Belgian Paralympian Marieke Vervoort said in Rio that she is considering euthanasia to escape a life of unbearable physical pain -- only not quite yet. 
 
 Vervoort, who won silver in the 400m wheelchair race at the Paralympic Games, played down earlier reports that she planned to be euthanized after her return from Brazil. 
 
 "I have my (euthanasia) papers in my hand, but I'm still enjoying every little moment. When the moment comes when I have more bad days than good days, then I have my euthanasia papers, but the time is not there yet," she told a news conference in Rio, Brazil, where the Paralympic Games are taking place. 
 
 After the Netherlands and Belgium, Luxembourg approved euthanasia but for adults only in 2009. 
 
 In Switzerland, doctors can assist a patient seeking to die but euthanasia itself is illegal ||||| Statement on Palliative Sedation 
 
 Approved by the AAHPM Board of Directors on December 5, 2014 
 
 Background 
 
 Palliative care supports patients whose diseases are associated with significant burden. Distressing symptoms exist on a spectrum from the most easily treated to the most refractory. Although preservation of awareness at the end of life is viewed as a priority for many, for some, the relief of symptoms may outweigh the desire to be conscious. Palliative sedation (PS), as defined in this statement, is the intentional lowering of awareness towards, and including, unconsciousness for patients with severe and refractory symptoms. 
 
 Statement 
 
 A primary objective of palliative medicine is the easing of suffering via pharmacologic and non-pharmacologic techniques. As with any medical procedure, PS must satisfy the criteria of having a specific clinical indication, a target outcome, and a benefit/risk ratio that is acceptable to both the clinician and patient. Palliative sedation is an intervention reserved for extreme situations. The use of palliative sedation should only be considered after all available expertise to manage the target symptom has been accessed. The level of sedation should be proportionate to the patient's level of distress. As with all treatments, patients, when able, should participate in the decision to use palliative sedation. Treatment of other symptoms should be continued alongside palliative sedation, because sedation may decrease the 
 
 patient's ability to communicate or display discomfort. 
 
 Palliative sedation raises ethical concerns when it significantly reduces patient consciousness to the degree that the patient is unable to substantially interact with others, does not have the ability or opportunity to change his mind, and is unable to eat and drink (thus potentially shortening survival in particular circumstances). Palliative sedation is ethically defensible when used 1) after careful interdisciplinary evaluation and treatment of the patient, and 2) when palliative treatments that are not intended to affect consciousness have failed or, in the judgment of the clinician, are very likely to fail, 3) where its use is not expected to shorten the patient's time to death, and 4) only for the actual or expected duration of symptoms. Palliative sedation should not be considered irreversible in all circumstances. It may be appropriate, in some clinical situations when symptoms are deemed temporary, 
 
 to decrease sedation after a predetermined time to assess efficacy, continued symptoms and need for ongoing sedation. 
 
 In clinical practice, palliative sedation usually does not alter the timing or mechanism of a patient's death, as refractory symptoms are most often associated with very advanced terminal illness. Practitioners who use palliative sedation should be clear in their intent to palliate symptoms and to 
 
 not shorten survival. Because patients receiving palliative sedation are typically close to death, most patients will no longer have desire to eat or drink. Artificial nutrition and hydration are not generally expected to benefit the patient receiving palliative sedation, however questions about the use of artificial nutrition and hydration should be addressed before palliative sedation is undertaken. (See AAHPM Position Statement of Artificial Nutrition and Hydration Near the End of Life). 
 
 There is no clear consensus or scientific evidence regarding the most appropriate medication(s) to effect palliative sedation. As elsewhere in medicine, the agent should be selected based on safety, efficacy, and availability. 
 
 Although the Academy recognizes that existential distress may cause patients to experience suffering of significant magnitude, there is no consensus around the ability to define, assess, and gauge existential suffering, to measure the efficacy of treatments for existential distress, and whether it is in the realm of medicine to palliate such suffering when it occurs absent of physical symptoms. Patients with existential suffering should be thoroughly assessed and treated through vigorous multidisciplinary efforts which may include involving professionals who are not usual members of the palliative care team (e.g., experts in psychological, family therapy, or specific spiritual services). If palliative sedation is used for truly refractory existential suffering, as for its use for physical symptoms, it should not shorten survival. 
 
 Bibliography 
 
 Broeckaert, B. (2011). Palliative sedation, physician-assisted suicide, and euthanasia: "Same, same but different"? AJOB, 11, 62 – 64. 
 
 Cherny, N.I., Radbruch, L., for the Board of the European Association for Palliative Care. (2009). European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care, Journal of Clinical Oncology, 23, 581 – 593. 
 
 Claessens, P. Menten, J., Schotsmans, P., Broeckaert, B. (2008). Palliative sedation: A review of the research literature. Journal of Pain & Symptom Management, 36, 310 – 333. 
 
 Claessens, P. Menten, J., Schotsmans, P., Broeckaert, B. on behalf of the Palsed Consortium. (2011). Palliative sedation, not slow euthanasia: A prospective, longitudinal study of sedation in Flemish Palliative Care Units. Journal of Pain & Symptom Management, 41, 14 – 24. 
 
 Kirk, T.W., & Mahon, M. M. (2010). National Hospice & Palliative Care Organization (NHPCO) position statement and commentary on the use of palliative sedation in immediately dying terminally ill patients. Journal of Pain & Symptom Management, 39, 914 – 923. 
 
 Kon, A.A. (2011). Palliative sedation: It's not a panacea. AJOB, 11, 41 – 42. 
 
 Maltoni, M., Scarpi, E., Rosati, M., Derni, S., Fabbri, L., Martini, F., Amadori, D., & Nanni, O. (2012). Palliative sedation in end-of-life care and survival: A systematic review. Journal of Clinical Oncology, 30, 1378 – 1383. 
 
 Morita, T., Akechi, T., Sugawara, Y., Chihara, S., & Uchitomo, Y. (2002). Practices and attitudes of Japanese oncologists and palliative care physicians concerning terminal sedation: A nationwide survey. Journal of Clinical Oncology, 20, 758 – 764. 
 
 Olsen, M.L., Swetz, K.M., Mueller, P.S. (2010). Ethical decision making with end of life care: Palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clin Prac, 85, 949 – 954. 
 
 Powers, C.L. & McLean, P.C. (2011). The community speaks: Continuous deep sedation as caregiving versus physician-assisted suicide as killing. AJOB, 11, 65 -66. 
 
 Quill, T.E., Lo, B., Brock, D.W. (2009). Last-resort options for palliative sedation. Annals of Internal Medicine, 141, 421 – 424 
 
 Schildmann & Schildmann. (2014) Palliative sedation therapy: a systematic literature review and critical appraisal of available guidance on indication and decision making. J Palliat Med, 17(5):601-611. 
 
 Vacco vs. Quill, 117 S.Ct. 2293 (1997). 
 
 Washington v. Glucksberg, 117 S.Ct. 2258 (1997). 
 
 Read other AAHPM position statements. ||||| (Reuters Health) - In the decade after Belgium legalized doctor-assisted death, the number of patients using it to end their lives rose nearly eight-fold, according to records of the national euthanasia control committee. 
 
 Most patients choosing this way to die between 2003 and 2013 were younger than 80 and had cancer. But the largest increases in euthanasia cases over that period was among people older than 80, those without cancer and those not expected to die in the near future, researchers report in the Canadian Medical Association Journal. 
 
 Belgium legalized euthanasia in 2002, and the new regulations allow a doctor to end a patient’s life if the patient requests it, has full mental capacity and has constant, unbearable physical or mental suffering, the researchers write. 
 
 Recipients do not need to have a deadly illness, but their illness must be incurable, said senior author Kenneth Chambaere of the University of Brussels. 
 
 There are a lot of concerns about the practice worldwide, and Belgium has come to be viewed as an example to learn from, Chambaere told Reuters Health by email. 
 
 “Also in Belgium the debate goes on, and this study is very helpful in gaining an overarching view of the practice,” he added. 
 
 Worldwide, The Netherlands, Belgium, Colombia and Luxemburg have legalized euthanasia, in which a doctor ends a person’s life, usually by administering barbiturate drugs. In Switzerland, Germany, Japan and Canada, doctor-assisted suicide, where patients take the final action themselves, is legal. 
 
 In the United States, physician-assisted dying is legal in only five states, Oregon, Vermont, Washington, California and Montana. 
 
 To determine how the practice of euthanasia has evolved since it was legalized in Belgium, the study team used data on cases recorded between 2003 and 2013 by the Federal Control and Evaluation Committee on Euthanasia. 
 
 The total number of doctor-assisted deaths over the decade after legalization was 8,752, with a steady increase each year. In 2003, there were 235 euthanasia cases, representing 0.2 percent of nationwide deaths, and in 2013, there were 1,807 cases, which was 1.7 percent of deaths. 
 
 In 2013, people with cancer made up 69 percent of all cases, and 65 percent were under age 80. 
 
 Among cases reported from Dutch-speaking parts of the country, the proportion involving people who were expected to die in the near future fell from 94 percent in 2003 to 84 percent in 2013. In French-speaking parts of Belgium, there was no significant change in this category. 
 
 Throughout the decade, palliative, or quality of life, care teams came to be consulted more often for euthanasia requests, even beyond what the law required. 
 
 The study findings might suggest an increase in euthanasia requests as patients became familiar with the law, and an increase in willingness to perform euthanasia as doctors became more experienced and society grew accustomed to the practice, the researchers write. 
 
 Among the study’s limitations is that the committee records did not contain details about the patients’ clinical circumstances and the exact nature of suffering that caused them to seek euthanasia, they add. 
 
 Marcel Zwahlen, a researcher at the Institute of Social and Preventive Medicine at the University of Bern in Switzerland, noted that not all societal groups approve of euthanasia. 
 
 “Most of the concerns surround the ‘free will’ of the patient and whether the decision to get help in committing suicide is really free, especially for cases with neuropsychiatric conditions,” Zwahlen said by email. 
 
 People may also fear that more vulnerable patients may be coerced into the decision, especially if they cannot afford care, said Zwahlen. 
 
 There have been no large scandals in Belgium, however, and the practice is becoming more normal, Zwahlen noted. 
 
 Although cancer was historically the most common cause, people suffering from Lou Gehrig’s disease, lung or heart problems and psychiatric issues may choose euthanasia. There is more ongoing debate about psychiatric patients, Chambaere said, adding that this will be the focus of his team’s future research. 
 
 Chambaere stressed the importance of continuing to monitor the practice of euthanasia, as issues can always arise in the future. 
 
 He is optimistic, though. “The study has a clear message that Belgium has had a predominantly positive experience in implementing euthanasia practice,” Chambaere said. 
 
 SOURCE: bit.ly/2c957I4 Canadian Medical Association Journal, online September 12, 2016. ||||| A new study on euthanasia trends in Belgium, which shows an increase in reported cases since legislation was introduced, provides lessons for countries that have legalized assisted dying. The research is published in CMAJ (Canadian Medical Association Journal). 
 
 In 2002, Belgium legalized the intentional ending of life by a physician at the patient's explicit request. The government introduced safeguards to protect patients, including a multidisciplinary review panel -- the Belgian Federal Control and Evaluation Committee for Euthanasia -- to ensure that each procedure was performed according to legal guidelines. 
 
 The Belgian researchers found that the number of officially reported euthanasia cases in Belgium increased from 235 in 2003 to 1807 in 2013 across all age groups and in all settings (home or care facility). They also noted an increase among people with conditions other than cancer and in people over age 80, a finding that was rare in the first few years after legalization. The highest incidence was consistently found among people dying with cancer, those younger than 80 years of age and those dying at home. There were also increases in euthanasia among people without terminal disease and those with psychiatric disorders, but their numbers remain relatively small. 
 
 "These findings might suggest an increase in the number of requests from these groups as they increasingly became aware of the legal possibility to request euthanasia. These findings might also reflect a decrease in reluctance to provide euthanasia within these groups as physicians became more experienced and the wider society became more familiar with these types of cases," writes Prof. Kenneth Chambaere, End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium, with coauthors. 
 
 Palliative care specialists were also consulted increasingly in the euthanasia procedure, though this is not a legal requirement. 
 
 "The increase in euthanasia among cases with noncancer diagnoses and nonterminal diseases emphasizes the importance of thorough evaluation and monitoring of the practice, since these situations are often more complex and may include psychiatric disorders and 'tiredness of life'." 
 
 "Given differences in developments between jurisdictions and even within Belgium, it is clear that societal and cultural contexts play a key role in how euthanasia practice has been adopted after legalization," the authors conclude.
– A child has been euthanized in Belgium for the first time since the country became the first to eliminate age restrictions for euthanasia two years ago, CNN reports. According to the BBC, the 17-year-old had an incurable disease, was in "unbearable physical pain," and requested euthanasia, as the law requires; "palliative sedation" was employed. No other information was provided, and Deutsche Welle reports the records outlining the patient's condition and the deliberation of the panel of physicians who weigh in are generally sealed. The teen's death, which had occurred in the past week, was announced Saturday, Reuters reports. The AFP cites a member of Belgium's federal euthanasia commission as saying the teen was not the first child to request euthanasia. Belgium legalized euthanasia for people with "constant and unbearable physical or mental suffering that cannot be alleviated" in 2002. It expanded its euthanasia law to cover all children under the age of 18 in 2014. In order to be euthanized, children must be able to understand what it means and get consent from their parent or guardian and "death must be expected in the near future." Belgium is the only country in the world that allows euthanasia without age restriction, and a study published this month found 1,807 total euthanasia deaths were reported in 2013, up nearly eight-fold from 235 in 2003. Reuters reports the 2013 figure represents 1.7% of deaths in the country that year. The Netherlands allows it for children older than 12. (This depressed 24-year-old was granted the right to die.)