of increased risk in these groups are not supported by evidence Physician assisted death (both voluntary BTLA active euthanasia and physician assisted suicide) has been openly practised in the Netherlands for more than 25 years and formally legalised since 2002. environment? In Oregon physician assisted death makes up about around one in 1000 fatalities each year without significant transformation in regularity over nine years. All sufferers have met the required criteria and a lot more than 85% had been also signed up for hospice programs. In Oregon one in 50 dying sufferers speak to their doctors about helped loss of life and one Skepinone-L in six speak to family.3 There appears to be very much discussion about end of lifestyle options therefore but relatively few situations of assisted loss of life. Oregon is one of the nation’s market leaders in various other markers of great end of lifestyle care including fatalities in the home opioid prescribing hospice enrolment and open public understanding about end of lifestyle choices.4 The Dutch procedures of doctor assisted death also have remained stable within the duration of four research 2 and hospice and palliative care have grown to be more prevalent lately. Can the burdens and challenges of the practices fall on vulnerable populations disproportionately? A report by Battin and co-workers published within this week’s that Skepinone-L analyses existing directories from Oregon and holland dispels several problems.5 They found no increased incidence of doctor assisted loss of life in seniors women people who have low socioeconomic status minors people in racial and ethnic minorities and people with physical disabilities or mental illness. The one exception was people with AIDS and studies from San Francisco completed before protease inhibitors were used also showed a high prevalence of physician assisted death in this population.6 These findings call into question the claim that the risks associated with legalisation will fall most heavily on potentially vulnerable populations. Are data available about these practices in places where physician assisted death is prohibited? Our study in 1998 assessed the secret practice of assisted death (both physician assisted suicide and voluntary active euthanasia) in the United States and found significantly higher rates (about one in 50 deaths) than in Oregon after legalisation.7 The data are not directly comparable as the study strategy we used safeguarded the surveyed doctors to ensure Skepinone-L anonymity (similar techniques are used to study other illegal practices). This may have meant how the participating doctors had been less representative and they reported their practice in a different way than if the practice had been legal. non-e the less it increases the chance that legalisation and rules with safeguards may protect instead of facilitate the practice. Is there some whole instances in legal conditions that usually do not meet the requirements and so are not reported? The most questionable instances in holland are the existence ending acts which have no explicit demands (about 1000 instances every year).1 2 8 Most however not many of these patients were suffering greatly and had lost Skepinone-L the ability to make decisions for themselves and many had previously given consent for physician assisted death under such circumstances. The number of such cases known as LAWER cases has decreased over time 2 but they still account for about 0.4% of deaths that fall outside the Dutch guidelines on voluntariness. It is tempting to attribute such cases to legalisation becoming a slippery slope but a recent study of six Western European countries-using the same format and questions as the Dutch studies-showed that four of the six countries where assisted death is illegal had a much higher incidence of LAWER cases than is seen in the Netherlands. In fact such instances had been more prevalent than instances of aided loss of life where voluntary consent was presented with (either voluntary energetic euthanasia or doctor aided suicide).9 What goes on in america to patients without mental capacity who are dying and whose struggling can’t be relieved by usual palliative measures? Proof based answers to the question are unfamiliar but there may very well be intense variability when confronted with the legal and moral doubt about responsibilities dangers and acceptable techniques.10 Clinical encounter shows that we cope with several patients using terminal sedation 11 a final resort that is legal in america because the 1997 US Supreme Court ruling. No formal monitoring can be designed for this practice in Oregon or somewhere else in the US. Limited data suggest that the practice of terminal sedation is highly variable and accounts for 0-44% of deaths depending on definitions and programmes.12 In the Netherlands.