2014-01, general practitioner, psychiatric disorders, not acted in accordance with the due care criteria
KEY POINT: psychiatric disorder
The patient, a woman in her eighties, had been suffering from depression for around 30 years. She had been treated with electroconvulsive therapy (ECT) and antidepressants. When these became ineffective, the patient declined further treatment. The patient’s general practitioner did not want to comply with her euthanasia request. She then turned to another physician, who was also a general practitioner, who spoke with the patient in the presence of her children on two occasions in quick succession, not long before her death. He consulted a SCEN physician who was also a general practitioner as the independent physician. The committee found that the notifying physician had not exercised the degree of caution that may be expected in the case of a psychiatric patient who requests assisted suicide. In this case the physician should have taken more time to talk to the patient, and should have spoken to her without her children present. As both the physician and the independent physician lacked psychiatric expertise, the physician should have consulted an additional expert.
The patient, a woman in her eighties, had been suffering from depression for around 30 years. While in the earlier years periods of depression sometimes alternated with manic episodes, in later years she suffered only from chronic melancholic depression, which became more severe in the last two to three years. Between ten to eight years and three to two years before her death, the patient received extensive electroconvulsive therapy and was treated with antidepressants. In the early years these treatments had brought temporary relief. When the ECT treatment ceased to be effective and began causing memory problems, and when subsequently the antidepressants ceased to work, the patient declined these treatments. From then on she only took paracetamol and a sleeping tablet. The patient was briefly admitted to a care home, but she did not like it at all. She felt she had to make a huge effort to become part of the group, and she was unable to do that. In addition, the home was due to be demolished at some point, which was not a reassuring thought. The patient’s suffering consisted of the fact that she no longer derived any pleasure at all from life, did not want her children or grandchildren to visit and was scared of everything. She was afraid to get up and afraid to go to bed, felt exhausted all day and did not have the energy to do anything. She had no hobbies; she just sat on the sofa all day. When she turned on the television she was unable to follow the programme. She saw nobody except her children. She was afraid to go outside because she feared the questions she might be asked. She was always worrying, had headaches (her head felt like a block of concrete), and suffered from palpitations and poor appetite. In the three years before her death she had lost 26kg in weight. The patient felt trapped in her home and in her body. She experienced her suffering as unbearable.
The patient had discussed euthanasia with her general practitioner before and signed an advance directive. As her general practitioner did not want to comply with her euthanasia request, she was registered with the End-of-Life Clinic (SLK) about a year before her death.
The SLK physician contacted the patient’s general practitioner. Around three weeks before her death, the patient asked this physician to actually perform the procedure to terminate her life. She then repeated her request.
In an interview with the committee, the physician gave a further, oral explanation, which included the following. The medical record includes correspondence from a clinical geriatrician, dating from the year of the patient’s death, a letter from a nurse practitioner at a psychiatric centre, dated two years before her death and a letter from a psychiatrist at the same psychiatric centre, dated eight years before her death, all of which the physician had been able to take note of. The patient had suffered from depression since menopause. She had been treated by psychiatrists for years with both medication and ECT treatment.
In the three years before her death these treatments had ceased to be effective. The patient did, however, suffer memory loss as a result of the ECTs. The patient considered the ineffectiveness of these therapies and their side-effects sufficient reason to decline further treatment. Based on his own experience and on the outcome of the multidisciplinary consultation at the End-of-Life Clinic, the physician was in no doubt that the patient could no longer be treated and was decisionally competent, and that granting her euthanasia request could be considered.
The physician did not consider consulting a second expert in addition to the SCEN physician. The SCEN physician had agreed that the patient could no longer be treated, was suffering unbearably and was not suicidal, but decisionally competent. The physician said he was not familiar with the guidelines of the Dutch psychiatry association (Nederlandse Vereniging voor Psychiatrie) on dealing with requests for assisted suicide from patients with a psychiatric disorder. He considered depression to be a chronic disease and did not see why it would be necessary to consult an additional independent physician who was also a psychiatrist for a patient with depression. The physician explained that he had spoken on the phone with the patient’s general practitioner. During that conversation, he understood that relations between the general practitioner and the patient were not good and that the general practitioner thought the patient was being overly dramatic. According to the general practitioner, the patient’s wish for euthanasia was not sufficiently palpable for him to grant it. A close family member subsequently registered the patient with the End-of-Life Clinic. Around six months before her death, the patient was referred by her general practitioner to a clinical geriatrician, at the recommendation of the End-of-Life Clinic. The clinical geriatrician had been involved in the period before the SLK physician had been in contact with the patient. The physician had however spoken to the clinical geriatrician on the phone.
When asked about the matter, the physician explained that he had spoken with the patient twice, once more than three weeks before her death and again three days later. The first time they spoke, two of the patient’s children had been present and the second time two other children of the patient’s. On neither occasion did he speak with the patient in private. The children had not joined in the conversation, however, except when he asked them to.
With regard to the voluntary and well-considered nature of the request, the absence of any prospect of improvement, and the independent assessment criterion, the committee considered as follows. In the event of a request for euthanasia or assisted suicide from a psychiatric patient, it is important to consult not only the independent physician but also one or more other physicians, including a psychiatrist, who can give an expert opinion on, among other things, the patient’s decisional competence and whether the patient’s suffering is without prospect of improvement. Assessing the decisional competence of such a patient, including a patient with chronic melancholic depression as in this case, requires special expertise. The same applies to being able to answer the question of whether any treatment options remain, despite the patient’s past medical history.
The notification details provided by the physician and the oral explanation he gave the committee did not demonstrate to the committee that he was sufficiently aware of this. He was not familiar with the guidelines of the Dutch psychiatry association on dealing with requests for assisted suicide from patients with a psychiatric disorder. Although he had taken note of correspondence from a psychiatrist dated eight years before the patient’s death and correspondence from a mental health institution dated two years before her death, he did not consult a psychiatrist himself to verify whether there were currently any treatment options and whether the patient’s request for euthanasia might be provoked by melancholic depression. The most recent correspondence found in the medical record was from a clinical geriatrician and consisted of advice concerning treatment. The contact by telephone with this expert two weeks before the patient’s death can only partly be viewed as consulting an expert as part of a euthanasia process. The physician’s explanation that he had not considered consulting a second independent physician because the SCEN physician had reached the same conclusion as he had, i.e. that the patient was decisionally competent, shows an underestimation of the requirements that an adequate assessment of the euthanasia request of a psychiatric patient must meet. This is especially relevant given that both he and the SCEN physician were general practitioners and as such had no specific psychiatric expertise.
In this specific case, the committee also observed that the physician spoke with the patient only twice within a very short timeframe and that the period between those conversations and the assisted suicide was very short. Moreover, those conversations both took place in the presence of her children and the physician did not speak with the patient in private.
By proceeding in this way, the physician was unable to demonstrate satisfactorily that he had been able to form a sufficiently substantiated opinion, not only with regard to the question of whether any treatment options remained, but also, and in particular, with regard to the consistent, voluntary and well-considered nature of a request made by such a patient, who apparently experienced frequent changes in her moods and emotions (she had recently been suicidal, but had also greatly enjoyed a holiday two years previously).
The committee found that the physician had not exercised the degree of caution that may be expected in the case of a psychiatric patient who requests assisted suicide. He should have taken more time to speak with the patient (privately, as well as in her children’s presence) and especially, since both he and the independent physician lacked psychiatric expertise, he should have consulted an additional expert, to ascertain in particular whether the patient was decisionally competent in relation to her request for assisted suicide.
The physician did not act in ccordance with the statutory due care criteria laid down in section 2 (1) of the Act.