2018-23, due care criteria not complied with
Non-straightforward notification, due medical care required, presence of emergency set, physician left the patient.
The patient, a man in his sixties, was diagnosed with a malignant tumour in the parietal pleura about a year before his death. In the final weeks before his death, his condition deteriorated sharply. His condition was incurable.
The physician was satisfied that this suffering was unbearable to the patient and with no prospect of improvement according to prevailing medical opinion. Nearly two weeks before his death, the patient asked the physician to actually perform the procedure to terminate his life. The physician concluded that the request was voluntary and well considered. The physician consulted an independent physician who was also a SCEN physician. She concluded that the due care criteria had been complied with.
At the request of the physician, ambulance personnel inserted an IV cannula. The physician began the euthanasia procedure by administering 1000mg of thiopental (a substance that induces a coma). As the patient did not go into a coma, the physician thought that the thiopental might have ended up under his skin instead of in the vein. He decided not to administer the second injection of 1000mg of thiopental, nor the muscle relaxant.
The physician first wanted the ambulance personnel to insert a new IV cannula. Before they arrived, the physician went to the pharmacy to get a new set of euthanatics. Because the IV cannula which the ambulance personnel had meanwhile inserted was not working, the physician then administered 2000mg of thiopental and 150mg of rocuronium (a muscle relaxant) via the first cannula, after which the patient died.
In his interview with the committee, the physician said that the procedure did not go the way he had hoped. In his region there is an arrangement between the physicians and pharmacists that the physician takes one set and the pharmacist always has an emergency set available. This way, no second set has to be prepared unnecessarily, which would then have to be thrown away.
After he had administered the 1000mg of thiopental, the physician noticed that it was taking a long time for the man to lose consciousness. As a result he thought the IV substances had gone under his skin. The physician said he then gave himself a time-out. He wanted to know whether the IV cannula had been inserted properly. When he injected the thiopental, however, he had not felt any abnormal resistance.
Meanwhile, the patient became increasingly sedated after all, and at a certain point he was unresponsive. Then, after about 20 minutes the physician checked the patient’s eyelash and pupil reflexes. They were absent. However, it had taken so long for the thiopental to take effect that the physician felt it was unsafe to inject the rocuronium.
After he had checked the patient’s condition, the physician left for the pharmacy to get a new set of euthanatics. The patient was in a peaceful state and the family were composed. The atmosphere was one of complete calm. The physician decided to go to the pharmacy because that would be quicker than having the pharmacist bring the euthanatics. In the meantime, the pharmacist would be able to prepare the substances.
The pharmacy was about one kilometre from the patient’s house and the physician drove there by car. He was away for about 10 minutes in total. A few minutes after the physician had left, the ambulance personnel arrived to insert a new IV cannula. The man was without medical supervision for only a short time. The physician emphasised that if there had been any instability on the part of the patient and/or his family, he would never have left. In that case he would have waited for the pharmacist to bring the euthanatics to him.
The committee found that the fact that the physician left the patient during the euthanasia procedure was not in accordance with the KNMG/KNMP ‘Guidelines for the Practice of Euthanasia and Physician- Assisted Suicide’ of August 2012, which the RTEs take as their guide. The Guidelines include the following standards which are relevant to this case:
- the physician must have an emergency set of intravenous euthanatics to hand;
- the physician remains present throughout the euthanasia procedure.
The committee found that these norms must be applied and that the physician has a responsibility to be aware of these norms and to act accordingly. The physician did not do so.
The committee found that the physician had not acted in accordance with the due care criterion laid down in section 2 (1) (f) of the Act. The other due care criteria were complied with.