2014-72, general practitioner, psychiatric disorders, voluntary and well-considered request
KEY POINT: psychiatric disorder
In her youth the patient, a woman in her sixties, had had a traumatic experience and had been emotionally neglected and mentally abused. She was diagnosed with a personality disorder with borderline characteristics. The patient was treated by a psychiatrist and a psychologist. Eight years before her death, the patient developed severe pain as a result of a herniated disc. Even after surgery the pain never disappeared completely. In the years that followed she had recurrent periods of depression and was suicidal. The patient underwent all the treatments in the depression protocol, but to no lasting effect. Her attending physicians were not willing to fulfil her wish for euthanasia. The notifying physician, who was affiliated with the End-of-Life Clinic (SLK) and who was not a psychiatrist, consulted a psychiatrist/SCEN physician and a non-practising general practitioner/SCEN physician as independent physicians. The physician exercised great caution: on the one hand he consulted various attending physicians (a general practitioner, psychiatrist and registered general psychologist) and the patient’s family, and on the other he consulted an independent psychiatrist to ascertain whether there were any realistic treatment options left and to establish whether the patient was decisionally competent in relation to her request for euthanasia.
In her youth the patient, a woman in her sixties, had had a traumatic experience and had been emotionally neglected and mentally abused. Twenty-three years before her death, she was diagnosed with a personality disorder with borderline characteristics. For several years around that period, the patient received outpatient treatment from a psychiatrist and a psychologist. She also took medication. The effects of these treatments were reasonably successful. The patient then experienced a relatively calm period lasting a decade, in which she did not seek psychiatric treatment, despite some angry outbursts and self-harm. Eight years before her death, the patient started to experience severe pain as a result of a lumbar disc herniation. She underwent surgery and was given pain relief. The pain never disappeared entirely, however.
From that period onwards, the patient never felt well again. In the years that followed, the patient suffered from recurrent periods of severe depression and attempted suicide four times using medication. All four attempts were thwarted, against her wishes. One year before the patient’s death, it was established that she was chronically and persistently suicidal, as a result of a severe personality disorder combined with recurrent periods of depression. The patient underwent all the treatments in the depression protocol, including electroconvulsive therapy, but to no lasting effect. She also received talk therapy. Her condition was incurable.
The patient’s medical history also included skin carcinomas on her legs, which occurred two years before her death and for which she received appropriate treatment.
The patient’s suffering consisted of complete exhaustion as a result of profound depressions, and pain and disability as a result of the herniated disc. Nothing interested her anymore. She no longer had the energy to watch television or read. She had to rest due to the exhaustion and the pain, but in those moments of rest she would start to worry. Every day was too much for her. She also suffered from the knowledge that there was no prospect whatsoever of improvement in her situation.
The patient had discussed euthanasia with several attending physicians before and also asked them to actually perform euthanasia. The last attending physicians did not want to fulfil her request, for reasons of their own. The patient subsequently registered with the End-of-Life Clinic about a year before her death. Four months before her death, the patient made her request to a psychiatrist from the clinic. More than six weeks before her death, the patient asked the physician, who was not a psychiatrist, to actually perform the procedure to terminate her life. She repeated her request during the next two visits by the physician and in telephone conversations.
The physician consulted two independent SCEN physicians, one of whom was an independent psychiatrist. The first independent physician – the independent psychiatrist – saw the patient four days before the termination of life was performed, after she had been informed of the patient’s situation by the physician and had examined her medical records.
In her report the first independent physician gave a summary of the patient’s medical history and the nature of her suffering. She also observed depressive characteristics during the interview. The independent physician concluded, partly on the basis of her interview with the patient, that there were no further alternative treatment options that would have a realistic chance of benefiting the patient. The patient was decisionally competent in relation to her request for euthanasia.
The second independent physician – a non-practising general practitioner – saw the patient two days before the termination of life was performed. He had previously been informed of the patient’s situation by the physician and had examined her medical records, including the findings of the first independent physician. In his report the second independent physician gave a summary of the patient’s medical history and the nature of her suffering. According to the second independent physician, the patient responded appropriately and her answers were clear. The patient was decisionally competent in relation to her request for euthanasia. The second independent physician concluded in his report, partly on the basis of his interview with the patient, that the due care criteria had been met.
In the event of euthanasia for a psychiatric patient, it is important to consult not only the independent physician but also one or more 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.
The documents provided by the physician made it sufficiently clear to the committee that he had exercised great caution. The physician consulted various attending physicians (a general practitioner, psychiatrist and registered general psychologist) and the patient’s family; he also consulted an independent psychiatrist to ascertain whether there were any realistic treatment options left and to establish whether the patient was decisionally competent in relation to her request for euthanasia.