2016-57, general practitioner, cancer, not acted in accordance with the due care criteria
KEY POINTS: deviation from the dosages prescribed in the Guidelines, no adequate coma check
In this case, the physician carried out the termination of life on request by intravenously administering 1500mg of the coma-inducing substance thiopental (instead of 2000mg) and 100mg of the muscle relaxant (instead of 150mg).
The committee asked the physician why he deviated from the Guidelines and how he established the depth of the patient’s coma before proceeding to administer the muscle relaxant. The physician was asked to explain his actions first in writing and later orally.
In his oral explanation the physician said that it was generally his experience that after thiopental has been administered patients quickly fall into a deep sleep. After half the dosage has been administered patients are usually already far gone. Normally, the physician always administered the maximum dosage of thiopental, immediately followed by the rocuronium.
It was not his practice to do a specific coma check. As regards the depth of the coma, he always relied more on his instinct (no breathing, patient completely relaxed) and the knowledge that the prescribed dosage of thiopental constitutes a substantial overdose. Nor had he ever encountered any problems after administering the rocuronium in the sense of a perceptible response from the patient.
The same was the case in this specific situation, in which he did not administer the maximum dosage of thiopental.
Inserting the cannula was troublesome, as the patient’s veins were difficult to access. A nurse with experience in anaesthesia inserted the cannula and advised the physician not to administer the euthanatic in one dose of 20ml, but to divide it over four doses of 5ml each. In order to handle the small vein with care, the physician followed this advice. When performing the euthanasia procedure, the physician first administered pain medication (lidocaine). He established that the cannula was inserted correctly. When he injected the first dose of thiopental, the patient responded, saying ‘ouch’. The physician administered the thiopental slowly because he was afraid the vein would burst. While he was injecting the first dose of thiopental, the patient fell asleep.
When it came to the third dose of thiopental, the physician encountered greater resistance. He thought the patient’s circulation was slowing down and remembered the advice of a colleague not to wait too long before administering the muscle relaxant because the muscle relaxant would not be absorbed by the body if there were no circulation. For that reason he decided to administer the muscle relaxant quickly. Thereupon the physician administered the first and second dose of rocuronium. He did not succeed in administering the third dose.
The physician therefore decided to check whether the patient had died. He could hear no hearttones and he established that there was no pupil reflex.
The committee found that the dosage of the coma-inducing substance administered by the physician was too low and that the physician did not do an adequate coma check before administering the rocuronium.
As a result it cannot be established that the coma was so deep that the patient would not have been able to perceive any stimuli whatsoever, nor was the physician able to convince the committee that this was the case.
Checking the depth of the coma properly was particularly important in this case, because the physician administered less than the prescribed dosage of thiopental. According to the committee, it could not be completely ruled out that the patient was in an insufficiently deep coma and that for that reason she might have perceived the effects of the muscle relaxant.
The committee could therefore only conclude that the physician did not exercise due medical care when terminating the patient’s life.