title: Discussing physician-assisted dying: physicians' experiences in the United States and the Netherlands.
abstract: OBJECTIVE
  This study aims to further our understanding of the experiences of physicians when discussing physician-assisted dying (PAD) within the context of doctor-patient relationships in various sociolegal settings. Although patients bring up PAD in diverse settings, little is known about how physicians experience these discussions, and such experiences have not been directly compared across countries.
  
  
  METHODS
  A total of 36 physicians in the Netherlands and the United States (including Oregon) were interviewed using individual semistructured interview guides. Interviews were conducted by a single interviewer, audiotaped, and independently transcribed. Inductive qualitative analysis, aided by NVivo7 software, directed purposive sampling of physicians until saturation was met. Multiple coders in a multidisciplinary team analyzed emerging themes and developed theory.
  
  
  RESULTS
  PAD discussions, which ranged from theoretical discussions to actual requests, could be gateways to discussions of other end-of-life issues important to patients and could strengthen doctor-patient relationships. Physicians found discussions to be emotionally intense, but often rewarding. Where PAD was legal, physicians utilized existing criteria to guide communication, and discussions were open and honest with patients and colleagues. Where PAD was illegal, conversations were less explicit, and physicians dealt with requests in relative isolation. In addition, physicians' views of their professional role, patients' rights, and religion influenced both their willingness to have and the content of PAD discussions.
  
  
  CONCLUSIONS
  Discussion of PAD is an energy-consuming, yet potentially enriching part of the doctor-patient relationship. Legal guidelines may help to provide structure and support for physicians when patients broach the topic of PAD.
authors.affiliation: Yale University School of Medicine, New Haven, Connecticut. jennifer.voorhees@yale.edu.
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Voorhees
authors.affiliation: Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands. Vrije University, End-of-Life Care Research Group, Brussels, Belgium.
authors.forename: Judith A C
authors.initials: JA
authors.lastname: Rietjens
authors.affiliation: Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Agnes
authors.initials: A
authors.lastname: van der Heide
authors.affiliation: Department of Internal Medicine, Section of Geriatrics, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Drickamer
mesh_terms: D000328:Adult; D032722:Advance Care Planning; D000368:Aged; D003142:Communication; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D009922:Oregon; D010817:Physician-Patient Relations; D010820:Physicians / Q000523:psychology*; D010821:Physicians, Family; D036301:Qualitative Research; D013727:Terminal Care; D014481:United States
keywords: Cross-cultural studies; Death and dying; End-of-life care; Ethics; Physician–patient communication