Attitudes towards End-of-Life Care in Italy: the Need for Education

The term End-of-life (EOL) care refers to the broad healthcare field that focuses on people experiencing a terminal illness, i.e. an advanced condition, which is deemed incurable [1].EOL care should not be confused with Palliative Care (PC), which is aimed to prevent or alleviate patients' suffering, regardless of the type and stage of disease.PC includes the EOL care, but it is not limited to EOL phase [2,3].EOL care, however, requires many decision-making competences and healthcare skills, including knowledge of PC [4].It is intended to alleviate the patients' suffering as well as promote dialogue with the patients and their families/ caregivers, support them from a psychological and spiritual point of view, and rationalize the allocation of healthcare resources.Italy represents a unique scenario among the Western countries, where a strong cultural and Catholic background influences the EOL-related issues. Attitudes toward End-of-Life CareThe situation among healthcare professionalsIt is known that decision-making is one of the core problems for physicians who care for dying patients, because it involves different competences including ethical aspects and legal issues.To note, it is also influenced by the cultural, social and religious background, whose importance for Italy has already been mentioned.In 2006, The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) published a consensus document on EOL decision-making, which included the definition of persistent vegetative state and directives on artificial nutrition and hydration (ANH) [5].This document has been constantly updated.Recently, a debate was raised by the highly publicized case of Ms. Eluana Englaro, a 36-year-old woman who remained in a persistent vegetative state due to a car accident in 1992.After 17 years in this state, she died on February 9 th , 2009, a few days after discontinuation of ANH [6].A survey of 22,219 physicians randomly selected from all specialties, administered after the controversies generated by Ms. Englaro's death, revealed an overall unfamiliarity with advance directives and the consequent decision-making in EOL situations [7].Despite adequate knowledge of definitions and diagnostic criteria, the experienced difficulties were primarily a reflection of Catholic influence on ethical and political debates and the absence of specific laws protecting the professionals' conduct in this arena.More recently, a survey by Barni, et al. [8] investigated the attitude of 400 Italian oncologists toward PC for patients with AbstractEnd-of-Life (EOL) care is directed towards patients with an advanced stage of a pathological condition, which has been deemed incurable.The concept should not be confused with 'palliative care', which is directed to alleviate an individual's suffering regardless the stage of a disease, even in concomitance with curative treatment.Italy represents a unique scenario, where a strong cultural and Catholic background along with the mass-media heavily influence perceptions of EOL issues.The Oviedo Convention (1997), which granted legal accreditation to advance directives, has neither been ratified nor incorporated into the Italian legal system.In the last 15 years, a few cases particularly publicized by the media brought attention to this topic.They evidenced the related national inadequacies, from public opinion to healthcare education, as well as the absence of specific EOL legislation.This manuscript provides an overview of different perspectives on EOL issues in the Italian context.Existing problems include scarce dialogue and communication between patients, professionals, and caregivers, absence of a uniform EOL education and training, limited research, and delays in legislation.Even though important steps have been taken, all these aspects contribute to an incomplete EOL culture.The achievement of strong EOL practices requires the following changes: a cultural shift through investment of time and resources, promotion of dialogue and communication, implementation of an appropriate training program, and introducing real values to advance directives.Therefore, successful implementation of these changes will lead to a proper legislative framework.