2019-100, due care criteria complied with
Non-straightforward notification, euthanasia one day after detention, End-of-Life Clinic, personality disorder characterised by dependence and avoidance, PTSD and depression.
The patient, a woman in her fifties, had ended the life of a close relative several years before her own death. Assessment of her mental health after she had committed this offence showed that she was withdrawn and dependent, showed little initiative and was socially anxious. The physician and the experts she consulted later diagnosed this as a personality disorder. After killing her relative, and attempting suicide immediately after, the patient developed post-traumatic stress disorder (an anxiety disorder that involves being constantly alert to a danger that no longer exists) and chronic depression with suicidal tendencies and severe self-reproach. After her conviction the patient was placed in the psychiatric ward of a prison. There, too, she attempted suicide several times.
During her detention, treatment with medication was started but this had no effect; the treatment caused only side-effects. In addition, the patient received psychotherapy, Eye Movement Desensitisation and Reprocessing (EMDR, a treatment method used with people who continue to have problems caused by a traumatic experience, such as an accident, sexual violence or other kinds of violent incident) and bereavement counselling. None of these treatments led to a substantial improvement in the situation, so the patient refused to continue with them. During the meeting the physician had with the committee, she explained that at her request another attempt at treatment was made. Anti-depressant medication was started again, to support EMDR therapy. The patient stopped taking the medication shortly after, as it was having too many side-effects. The EMDR stirred up emotions and caused the patient to relive events, and she was unable to cope.
The patient was suffering from her inability to give shape to the rest of her life due to her feelings of guilt, her personality disorder and her post-traumatic stress disorder. She felt her life was futile and meaningless; she saw no future prospects for herself. The relative in question had been the focal point of her life. The patient had no social contacts left and was unable to build new ones. The future held nothing for her and she regretted that her suicide attempts had failed.
The patient experienced her suffering as unbearable. The physician, a psychiatrist specialised in mood disorders, was satisfied that this suffering was unbearable to her and without prospect of improvement according to prevailing medical opinion. There were no alternative ways to alleviate the patient’s suffering that were acceptable to her.
After many conversations, the physician was satisfied the patient was suffering unbearably and without prospect of improvement and that she was so badly traumatised that no treatment whatsoever could change her situation. The physician talked to the patient about waiting several months after her release and then undergoing another course of treatment, but the patient said she could not summon the energy to do so. For her there was no life without her relative. The physician was of the opinion that any treatment would be doomed to fail, as treatment requires a will to change. As treatment in the psychiatric ward of the prison had failed, the physician was satisfied that treatment in a psychiatric institution (after committal) would not be successful either.
The physician consulted an independent psychiatrist, specialised in forensic psychiatry, and a second independent physician, who was also a psychiatrist. In their opinion too, the patient was suffering unbearably and without prospect of improvement, and there were no reasonable alternatives that would alleviate her suffering.
The physician was satisfied that the request for euthanasia was voluntary and well considered. This was confirmed by the independent psychiatrist and the independent physician. Continuing to live after her release was in no way whatsoever a reasonable alternative for the patient.
At the request of the physician, the aforementioned independent psychiatrist also assessed the patient’s decisional competence. In the psychiatrist’s opinion the patient had thought carefully and thoroughly about her request for euthanasia. She was consistent and clear in relation to her request. The request for euthanasia was related to psychiatric problems, but was not driven by those problems alone.
The independent psychiatrist concluded that the patient was decisionally competent in relation to her consistent and clearly expressed request for euthanasia. On the day when the patient was released from prison after serving her sentence, she went to a hospice. The procedure to terminate her life took place there that same day.
Before reviewing the case in terms of the due care criteria, the committee noted that this was a complex case that was dominated by the patient’s psychiatric problems and in which existential feelings of guilt played an important role. In addition there the exceptional circumstance of the patient’s imprisonment.
The committee noted that physicians must exercise particular caution when a euthanasia request results (largely) from suffering arising from a psychiatric disorder. Such cases often involve complex psychiatric problems, and require specific expertise. Particular caution must be exercised when assessing the voluntary and well-considered nature of the request, the unbearable nature of the suffering, the absence of any prospect of improvement, and the lack of a reasonable alternative. In such cases, the physician must always also consult an independent psychiatrist in addition to the regular independent physician (Euthanasia Code 2018, pp. 43-44).
It can be established that the physician complied with this requirement for particular caution by consulting both an independent physician, who was also a psychiatrist, and an independent psychiatrist, who was specialised in forensic psychiatry.
Voluntary and well-considered request
The committee found that in this case the physician could be satisfied that the patient’s request was voluntary and well considered. On this point, the committee noted the following. The possibility that the psychiatric disorder had impaired the patient’s powers of judgment must be ruled out. The physician had to take particular note of whether the patient had shown she was able to grasp relevant information, understood her disease and was consistent in her deliberations.
The reports provided by the physician of the 12 conversations she had had with the patient showed that the patient’s wish to die was consistent and motivated. From the very first conversation, the patient indicated that since the death of her relative she no longer wished to go on living. Her request was not influenced by anyone else (external voluntariness) and the physician was satisfied that the patient was able to grasp relevant information, was able to explain clearly why she wanted euthanasia and was consistent in relation to her request (internal voluntariness).
The physician was satisfied that her request was voluntary and well-considered and this was confirmed by the independent psychiatrist and independent physician consulted. The committee found that in the circumstances was voluntary and well considered.
Unbearable suffering without prospect of improvement and absence of a reasonable alternative
In the committee’s opinion, in this case the physician could be satisfied that the patient’s suffering was unbearable and without prospect of improvement, and that the physician and the patient together could be satisfied that there was no reasonable alternative in the patient’s situation. On this point, the committee noted the following. The unbearable nature of the suffering depends on the individual patient’s perception of their situation, their life history and medical history, personality, values and physical and mental stamina. It must be palpable to the physician, also in light of what has happened so far, that this particular patient’s suffering is unbearable and with no prospect of improvement (Euthanasia Code 2018, pp. 23-24).
A patient is regarded as suffering with no prospect of improvement if the disease or disorder causing the suffering is incurable and there are no means of alleviating the symptoms so that the suffering is no longer unbearable. The diagnosis and the prognosis are central to the assessment of whether there is no prospect of improvement. This must be determined in the light of whether there are realistic options, other than euthanasia, that would end or alleviate the symptoms. ‘No prospect of improvement’ must be seen in relation to the patient’s disease or disorder and its symptoms. There is no prospect of improvement if there are no realistic treatment options that may – from the patient’s point of view – be considered reasonable. It is thus clear that the assessment of the prospect of improvement is closely linked to determining whether there is a reasonable alternative that would alleviate or end the suffering (Euthanasia Code 2018, p. 23). The physician and the patient must together arrive at the conclusion that no reasonable alternatives are available to the patient. The perception and wishes of the patient are important. There is an alternative to euthanasia if there is a realistic wayof alleviating or ending the suffering which may – from the patient’s point of view – be considered reasonable (Euthanasia Code 2018, p. 26). It is noted in the Euthanasia Code that the proposed alternative must have positive effects within a reasonable period of time and that the patient may always refuse treatment although such a refusal may have consequences for the euthanasia request (Euthanasia Code 2018, p. 26-27).
In the committee’s opinion it can be deduced from the reports of the 12 conversations between the patient and the physician that the physician made a thorough assessment of both the nature of and background to the patient’s suffering and the question of whether there were any reasonable alternatives. In the committee’s opinion, the independent psychiatrist and independent physician consulted confirmed the physician’s conviction that the patient’s suffering was unbearable and without prospect of improvement and the physician and the patient together could be satisfied that there was no reasonable alternative in the patient’s situation.
In the committee’s view, the other due care criteria were also fulfilled.