Dutch euthanasia

1
Dutch euthanasia an easy death? For whom?

• Philip Esterhuizen RN, BA(Cur) MScN, PhD

2
Philosophy of care

• Care delivery can only be referred to if the
  needs of the individual patient are taken into
  account when providing care and professional
  treatment.

3
Definition

• Euthanasia is a deliberate life-ending activity
  undertaken by someone other than the person
  involved at their request.
• Deliberate action of ending life
• by a person, other that the person involved
• at their request

4
What euthanasia is not

• Non-commencement or stopping of treatment because
  the patient refuses treatment.
• Non-commencement or stopping of treatment because
  (further) medical treatment would be futile.
• Alleviation of suffering by administering
  prescribed pain medication.
• Ending life without request.

5
Physician assisted dying in the Netherlands

• Per year
• 140.000 deaths
• 30.000 discussions about PAD
• 9.000 explicit requests
• 3800 die with physician assistance
• 3520 euthanasia (2,5 of all deaths)
• 280 assisted suicide (0,2 of all deaths)
• 3000 diagnoses of cancer

6
Cohort study on physician assisted dying in
Utrecht

• 198 patients with terminal cancer
• (life expectancy lt 3 months)
• 140 agreed and could complete questionnaire
• Median age 60 years
• 59 discussed euthanasia (age no difference)
• 21 requested euthanasia (age no difference)
• 14 died with physician assistance (age no
  difference)

7
Predictors for requesting physician assisted dying

• Univariate (plt0,1)
• Pain
• Insomnia
• Depressed mood
• Religion
• Multivariate
• Pain (odds ratio 1,37)
• Religion (odds ratio 0,21)

8
Depression and physician assisted dying

• Patients with depressed mood 23,
• 44 requested euthanasia
• Patients without depressed mood 77,
• 15 requested euthanasia
• Patients with request
• 50 with depressed mood (HADS scoregt 20 points)
• 8 major depression (DSM IV)

9
Grief in family and friends of patients dying
Mean score (95 CI) Mean score (95 CI)
Euthanasia (n189) Natural death (n315)
Inventory of traumatic grief (ITG) 39 (38-41) 45 (43-47)
Impact of event scale (IES) (posttraumatic stress reaction) 13 (11-15) 18 (16-19)
Symptom check list (SCL-90) (psychiatric symptomatology) 116 (111-120) 121 (118-125)
significant
10
Euthanasia and assisted suicide

• Is punishable by Dutch Law
• An exception is
• A doctor,
• Provides euthanasia on request of the patient,
• Adheres to the guidelines and demands of care,
• Reports to the coroner in accordance to the Law.

11
Guidelines and demands (1)

• The doctor must be convinced that the patients
  request is enduring, voluntary and
  well-considered.
• The doctor must be convinced that the patients
  suffering is hopeless and unbearable.
• The doctor must have informed the patient about
  their situation and the prognosis.

12
Guidelines and demands (2)

• The doctor and patient have reached the
  conclusion that there is no other reasonable
  solution for the situation.
• The doctor has consulted at least one other
  independent doctor who has seen the patient and
  provided a written report regarding adherence to
  the guidelines.
• The doctor has carried out the euthanasia or
  assisted suicide with care.

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Advance directives

• Sixteen en older,
• An advance directive written prior to the patient
  being unable to communicate,
• Has same status as verbal request.
• Advance directives have no specific template and
  are not bound to a limited time frame.

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Minors

• A patient 16 and older, who is able to reasonably
  access their situation, can request euthanasia if
  the parents or guardian have been involved in the
  decision-making.
• A patient between 12 -16, who is able to
  reasonably access their situation, can request
  euthanasia if the parents or guardian have
  consented.

15
Procedure (1)

• Well documented written report is essential and
  the prescribed forms must be filled out.
• Report must be made to the coroner.
• Coroner presents report to regional commission
  for examination regional commission consists of
  an odd number of representatives including a
  lawyer, a doctor and an expert in ethics.

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Procedure (2)

• Commission can request further information from
  the doctor or any of the team involved in the
  activity.
• The doctor is provided with the commissions
  judgement within six weeks of submitting the
  report and can be, if necessary, extended by
  another six weeks.
• If necessary, or requested, the commission will
  provide the doctor with further explanation on
  the findings.

17
Procedure (3)

• If the commission finds that the doctor has not
  adhered to the guidelines and demands, a report
  is filed with the Attorney General and the
  Regional Inspector of Health. The doctor is
  informed of this.
• The Public Prosecutor can, based on the report,
  call for an investigation and commence with
  criminal prosecution.
• All parties are legally obliged to provide any
  information requested to further the
  investigation.

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Procedure (4)

• The Regional Inspector of Health can put the case
  to the Regional Disciplinary Tribunal.
• The Regional Disciplinary Tribunal examines
  whether any acts or omissions have contravened
  the acceptable standard of care demanded of the
  health care professional by the Individual Health
  Care Professions Act.

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In euthanasia

• The patient has the right to request, but no
  obligation to receive.
• And
• Medical staff have an obligation to listen,
  advise and refer on moral grounds, but
• the right to refuse,

20
Approach to schooling on moral decision-making

• Principle-based ethics
• The value of life
• Goodness/no harm
• Justice
• Truth telling
• Autonomy
• Beneficence

• Care-based ethics
• Moral attention
• Sympathetic understanding
• Relationship awareness
• Accommodation
• Response

21
Evaluation of schooling

• Participant satisfaction
• Questionnaire
• Semi-structured interviews

22
Results from the questionnaires

• Assertiveness
• Current and adequate knowledge
• Discussion techniques
• Morally challenging situations
• Organizational
• Multi-disciplinary interaction
• Direct patient care

23
Results from the semi-structured interviews

• Positive influence within the nursing team
• Increased knowledge of jurisprudence
• Improved communication
• Increased knowledge and application of ethics of
  caring / principle-based ethics

24
The hospital should do the patient no harm
25
Contact information

• Philip Esterhuizen
• p.esterhuizen_at_hva.nl