2017-07, due care criteria complied with

Non-straightforward notification, establishing the unbearable nature of suffering can be very difficult.

The patient, a woman in her eighties, had suffered from dizziness for four years. She constantly felt light-headed and movement, particularly turning, caused her to feel nauseous. Three years before her death, she was diagnosed with an inner ear disorder on both sides.

She experienced persistent problems because of severely impaired automatic balance control, including orientation and gaze stabilisation. Typical problems included fluctuating visual acuity, reduced balance control with an increased risk of falling, sudden fatigue, and nausea when looking at moving images.

Three years before her death she suffered a heart attack and eighteen months before her death she was fitted with a pacemaker. In the last six months before her death her functioning deteriorated considerably. Around three months before her death, the patient had her pacemaker turned off and stopped taking medication, except for medication to help her sleep.

The patient’s suffering consisted of the progressive deterioration in her functioning. Performing activities of daily living cost her an increasing amount of time and effort. She felt very restricted by her balance problems and the fact that she tired quickly. She always had to be careful when turning round. She had to move her head slowly, otherwise she would feel ill and nauseous. She fell down regularly. She was no longer able to do several things that were very important to her, such as going for walks in the countryside, walking to the supermarket and doing her own shopping, reading books, listening to music, and participating in social occasions. She experienced less and less joy in life.

The patient had always been a lively and sociable person, and attached great value to her independence. She was suffering from her physical decline, the loss of joy in life, not being able to enjoy social relationships with other people, and the imminent loss of independence. She experienced her suffering as unbearable.

The patient had discussed euthanasia with her general practitioner before. The latter was unwilling to grant her request for euthanasia, because she found it difficult to establish the unbearable nature of the patient’s suffering and felt pressured by the patient. The patient then contacted the End-of-Life Clinic (SLK).

The physician, together with an SLK nurse, spoke with the patient on three occasions. At first, the physician had difficulty establishing the unbearable nature of her suffering, mainly because of the cheerful manner in which the patient presented herself. The woman tried to emphasise the positive aspects of her situation and dismiss the misery. She characterised herself as someone who knew how to act decisively, showed great willpower, was optimistic and resilient, had few needs and was not quick to complain. It was precisely these characteristics that made it difficult for the patient to describe her unbearable suffering. Nonetheless, by the time of their third meeting, the physician was satisfied that her suffering was unbearable.

According to the SCEN physician consulted, the crucial question was whether a person who could still do so much and appeared so energetic could be said to be suffering unbearably. The patient made it clear to him that she herself experienced her suffering as unbearable. This was caused mainly by the progressive loss of function and the loss of her enjoyment of life. She could still appear to be enjoying life, but no longer experienced the feeling that went with it. The independent physician was able to understand the patient’s request for euthanasia and concluded, albeit it somewhat hesitantly, that her suffering was unbearable.

The committee noted the following in connection with the unbearable nature of the patient’s suffering. At first, the physician doubted whether the patient was suffering unbearably, because of the cheerful and optimistic manner in which she presented herself. After speaking with the patient several times and consulting with colleagues, the physician gradually became convinced that the social isolation and the loss of any meaningful way to spend her time, which resulted from her deafness and dizziness, constituted unbearable suffering for the patient.

She had led an intellectually rich and independent life, and that was now ending in a situation marked by anxiety because of dependence, danger of falling, isolation and the prospect of further debilitation.

In view of the above facts and circumstances, the committee found that the physician could be satisfied that the patient’s request was voluntary and well considered, and that her suffering was unbearable, with no prospect of improvement. The other due care criteria were also fulfilled,  in the committee’s view.