QUALITY OF LIFE, LEGAL AWARENESS OF EU-THANASIA AND DISABILITY

Introduction: a central problem in medical practice is the resumption of good quality of life in chronically ill patients with disability. The unresolved health problems of chronically ill patients with disability inevitably lead to increased consumption of health services and create a risk of a euthanistic predisposition. Aim: to study the relation between quality of life and legal awareness of euthanasia in chronically ill patients with disability. Material and methods: Material: The study includes 173 polymorbid patients with disability, evaluated by the Territorial Expert Medical Commission (TEMC) in the Varna region. The research was conducted during the time period of July-December 2021. Methods: sociological methods - individual and group examinations and statistical methods - analysis ( χ 2), variance analysis, correlation analysis (r), regression analysis (â). Results and discussion: we establish a predominant influence of the “Environment” and “Physical health” domains while assessing the legal awareness of euthanasia in this vulnerable group in society. Pain and low quality of life, determined by the lack of social support, are important factors in deciding on euthanasia. Conclusion: the low quality of life of chronically ill patients with a disability requires more adequate opportunities, ensuring optimal disease management. Bulgarian society suffers a significant insufficiency of palliative/hospice care, which makes legalizing euthanasia at the moment a premature decision.


INTRODUCTION
A central problem in medical practice is the resumption of good quality of life in chronically ill patients with disability [1,2]. The results of the research on the quality of life (QL) have a high informative value for the effectiveness of the health system through the eyes of the end consumer. The unresolved health problems of chronically ill patients with disability inevitably lead to increased consumption of health services and create a risk of a euthanistic predisposition, because of which we studied the relation between quality of life and legal awareness of euthanasia [3,4].
The aim is to study the relation between quality of life and legal awareness of euthanasia in chronically ill patients with disability.

MATERIAL AND METHODS
The presented study includes 173 patients evaluated and reevaluated by the Territorial Expert Medical Commission (TEMC) in the Varna region. The research was conducted during the time period of July-December 2021. The patients suffer from polymorbidity and disability (above 50%). The questionnaire for the assessment of legal awareness of euthanasia includes 28 questions, divided into three domains, corresponding to the three elements of its structure: cognitive element (I -information) concerning awareness of the problem; psychological element (A -Attitude), expressing the patients' attitude towards euthanasia; behavioural element (C -Conduct), pertaining to the patients' preparedness in legally significant situations. WHOQOL-BREF (WHO generic questionnaire) -26 questions; four-domain structure: Physical health, Psychological health, Social relationships, Environment. The data is processed with SPSS v.24.0 for Windows.

RESULTS AND DISCUSSION
The data shows the significance of separate domains of quality of life and their determinant impact on the polymorbid patients' legal awareness of euthanasia. The results are similar to those obtained in a study of 305 polymorbid patients with disabilities ((main investigator: P. Mancheva MD, PhD; Protocol/permission from 13. 10. 2011 by Ethical Commission MU-Varna). We establish a predominant influence of the "Environment" and "Physical health" domains while assessing the legal awareness of euthanasia in this vulnerable group in society. The applied multi-regression analysis confirmed the results obtained from the other research methods in the study [5,6]. There is a predominant influence and significant importance of pain and the "Environment" domain on the overall assessment of QL while assessing legal awareness ( Table 1): The increase in the overall assessment of QL is associated with a decrease in the desire for passive euthanasia. There is a decrease in the approval of active euthanasia with an increase in the overall assessment of QL and a similar tendency in the "Physical health" domain. It turns out that the low quality of life definitely has an effect on the legal awareness of this vulnerable group. This significance lies in increasing the approval of euthanasia in general. At the same time, the low QL leads not only to the approval of both types of euthanasia -passive and active, but also increases the desire and readiness for their implementation. The study of the significance of the separate domains of quality of life while assessing the legal awareness of euthanasia ascertained a predominant influence of the "Environment" and "Physical health" domains. The results of the study show better awareness of the nature and regulations of euthanasia among respondents with a higher evaluation of QL in the "Physical health" domain. The improvement of QL, related to a higher evaluation in the "Physical health" domain, leads to a reduction in support for the legalization of euthanasia in our country. The high evaluation in this domain often leads to a refusal of euthanasia from family members.
The evaluation in the "Physical health" domain emphasizes the importance of the somatic aspect of the disease while assessing legal awareness. The presence of three or more chronic, debilitating diseases leads to a lower evaluation in the "Physical health" domain and is the reason for the approval of legal regulation of euthanasia in our country. The study among this vulnerable group reveals an approval for passive euthanasia and an increase in the readiness for active euthanasia. The low evaluation in this domain leads to an increased approval of euthanasia among polymorbid patients. It is related to the desire to refuse treatment and to the increase in consent for the legalization of euthanasia. This data shows a growing necessity for healthcare improvement, as well as an increase in the intended budget for healthcare. The study demonstrates the impact of pain on the three elements of legal awareness among the respondents. The increase in pain intensity drives polymorbid patients to seek more information on euthanasia as a possible way out of their hopeless situation. This makes them very well informed about the problem, determines their approval and motivates their preparedness in legally significant situations. The data shows that the strong, chronic and unresponsive to treatment pain motivates this vulnerable group's readiness "for" the legalization of euthanasia in our country. The results from the research on the influence of the "Environment" and "Social relationships" domains reveal the gravity of health's social element in the formation of legal awareness of euthanasia in polymorbid patients.
The low evaluation in the "Environment" domain is directly related to the behavioural element of legal awareness, as it increases the consent for euthanasia and leads to readiness for its implementation. The conclusion is that the pain and low QL, determined by the lack of social support, are important factors in deciding on euthanasia [7]. This is likely due to the deep economic decline caused by the pandemic, with unemployment and inflation as its con- sequences, incl. difficult access for chronically ill patients to health care because of the overload of the health system with covid patients. There is an insufficiency in healthcare funds, a decrease in the opportunities to find work, stagnation of pension and salary growth, etc. Chronically ill patients with disability are a vulnerable group in society that has low financial income and pronounced difficulties in finding work, as well as an everyday need for health and social care [8,9,10]. The low evaluation in the "Environment" domain is directly related to the impasse in which chronically ill patients find themselves and correlates to the increase in their consent for passive and active euthanasia and their readiness for their implementation. 4. Riisfeldt TD. Weakening the ethical distinction between euthanasia, palliative opioid use and palliative se-

CONCLUSION
Relieving the suffering and affecting the pain, as well as other problems of physical, mental and social nature, are within the scope of palliative medicine, which is at the dawn of its development in our country. Patients from this group of invalids, who need palliative care to change their quality of life and not the legalization of euthanasia, are being recruited. The organization of our healthcare does not provide sufficient and adequate opportunities for these patients, allowing optimal prolonged disease management. Bulgarian society suffers from serious insufficiency of palliative/hospice care, which makes the legalization of euthanasia at the moment a premature decision.