2017-73, due care criteria not complied with

Publication | 01-01-2017

The patient, a woman in her seventies, had been diagnosed with metastasised cancer of the head of the pancreas one and a half month before her death. The patient’s condition was incurable. The patient could only be treated palliatively (care aimed at improving quality of life).

The patient’s suffering consisted of extreme fatigue, increasing dependency on others and the fact that she was bedridden. She was nauseous and could not eat or drink properly. The patient, whose husband had died shortly before, was suffering from her rapid decline. She experienced that suffering as unbearable. The physician was satisfied that the patient’s suffering was unbearable to her and with no prospect of improvement according to prevailing medical opinion.

The patient first discussed euthanasia with her physician half a year before her death, together with her husband, who was ill. They had both said that if they were in unbearable pain and were bedridden, had no quality of life and were expected to die in the near future, they would want no further treatment except sedation or euthanasia.

Several months later the patient confirmed this wish. After learning of her diagnosis, the patient discussed euthanasia with the physician on several occasions. Just over two weeks before her death, the patient asked the physician to actually perform the procedure to terminate her life. She later repeated her request.

Two days before the termination of life, the patient fell into a coma, due to a major cerebral infarction (stroke). The evening before the termination of life and shortly before the procedure was carried out, the patient briefly displayed improved consciousness. When asked by the physician whether she indeed wanted euthanasia, she squeezed his hand and nodded vaguely.

The physician concluded that the request was voluntary and well considered. It was clear to the physician that the patient was suffering at that time: she was in pain and she was moaning and crying.

The physician consulted an independent physician who was also a SCEN physician. He saw the patient a day before she died. The independent physician noted that the patient was responding when spoken to, but that in his assessment she was unable to respond to questions. According to him she did not appear to be in pain, and there was no shortness of breath or discomfort. The unbearable nature of her suffering – although impossible to assess now according to the independent physician – consisted of loss of independence and the fact she was bedridden.

In his report, the independent physician concluded, partly on the basis of the physician notes and conversations with the physician and the patient’s children, that the due care criteria had been met.

After studying the details of the notification and a further written explanation by the physician, the committee had additional questions regarding the patient’s wishes, her unbearable suffering and her state of consciousness the day before her death.

The physician gave a further explanation regarding the patient’s background and her wish for euthanasia. The patient was in a turbulent situation: her husband, who had suffered from cancer, had died a few months earlier following a euthanasia procedure. Not long after, she was diagnosed with metastasised cancer of the head of the pancreas. In several conversations between the physician and the patient, she said that she would want euthanasia too.

When her husband’s request for euthanasia was carried out, she and her children had felt it had been a good process, in which they were able to say goodbye together. According to the physician, the patient did not want to lose her independence. She did not want to become bedridden, suffer unbearable pain and/or experience severe shortness of breath. The euthanasia process had not actually commenced yet, but that was the intention.

Earlier, it had been discussed with the patient that she would draw up an advance directive. It was believed than an advance directive had been drawn up digitally, but due to circumstances (the patient suddenly having to move in with her son; the file probably having been saved on her husband’s computer) it could not be produced. According to the children, the advance directive existed. After the cerebral infarction the patient was no longer able to express her wish for euthanasia in words.

The patient’s children wanted the physician to grant that wish. The physician explained that he had considered palliative sedation and discussed this with the family. Given the unpredictability of her condition, in which it might still be days or even a week before she died, this was not an option for the family. They said this was the opposite of what she would have wanted.

As regards the confirmation of the wish for euthanasia on the evening before euthanasia was performed, the physician was aware that these non-verbal signs were a question of interpretation. However, his view was that on the basis of these signs he could conclude that the patient actually wanted euthanasia. The physician also indicated that she was sweating and grimacing. He was satisfied that the patient was suffering unbearably and was in pain.

The committee noted that the patient was in an irreversible state of reduced consciousness before the euthanasia process between the physician and the patient started. In order to proceed with euthanasia in such a case, there must at least be an advance directive drawn up by the patient. There must also be signs that the patient may be suffering and the independent physician will have to see the patient (Euthanasia Code 2018, p. 48).

The committee noted from the physician’s reports that no advance directive was produced. The committee also noted that the independent physician consulted by the physician saw the patient. However, the independent physician indicated that the patient was unable to express her wish for euthanasia in words, was unable to respond to questions and did not appear to be in pain. The independent physician’s findings with regard to the patient’s condition did not match those of the physician.

The committee considered this difference in observation between the independent physician and the physician to be conceivable in view of the patient’s fluctuating state of consciousness. As regards the communication between the physician and the patient prior to euthanasia being performed, in the interview with the physician it was established that no prior agreement had been made as to how this communication should be interpreted, not even as an introduction to the question.

The committee therefore concluded that the nodding and hand squeezing were insufficient in this specific situation to qualify as confirmation of the patient’s wish for euthanasia. The fact that there was no underlying advance directive made this all the more problematic.

In view of the above facts and circumstances, the committee found that the physician could not be satisfied that the patient had made a voluntary and well-considered request. The committee also found that the physician’s conviction that the patient was suffering unbearably was insufficiently supported by facts or circumstances that were at play in the period shortly before euthanasia was performed.

The physician did not act in accordance with the due care criteria.