2015-52, general practitioner, cardiovascular disease, voluntary and well-considered request, independent assessment

Publication | 01-01-2015

After suffering a massive CVA, the patient was no longer able to communicate. The patient had discussed euthanasia with her physician before and drawn up an advance directive. On the basis of the advance directive, patient records, the information given by the physician and conversations with the patient’s family, the independent physician concluded that the patient’s euthanasia request was voluntary and well-considered. The independent physician found her suffering visibly and palpably unbearable. There was no prospect of improvement. It was clear to the independent physician from the information given by the physician that the latter had discussed the situation extensively with the patient. They had together reached the conclusion that there were no reasonable alternatives available.

Two weeks before the procedure to terminate her life was performed, the patient, a woman in her eighties, suffered a very extensive cerebral infarction. As a result she became hemiplegic, completely aphasic and suffered from severe cognitive impairment.

In the previous year the patient had gradually deteriorated; she was suffering from earlystage vascular dementia as a result of multiple CVAs and TIAs. There were no rehabilitation options available, as the relevant area of the brain had been affected too severely. Her condition was incurable.

The patient’s suffering consisted of being unable to do anything and being fully dependent on other people. She was slumped in her wheelchair due to poor trunk balance. She was hardly able to understand anything said to her and hardly able to communicate. The burden of her suffering was apparent from her demeanour. This was confirmed by the attending geriatrician.
She would have to be admitted to a nursing home where she would be like a vegetable.

The patient had discussed euthanasia with the physician before. In the final months before the procedure to terminate her life was performed she had on several occasions said emphatically to the physician (her general practitioner), her geriatrician, and her family that she did not want to experience late-stage dementia, as her mother had done. She stated specifically that she wanted euthanasia as soon as she became dependent and would have to be admitted into a nursing home.

Several days before her death, in a moment of lucidity, the patient was able to make clear to her daughter in the presence of others that she indeed wanted euthanasia.

The advance directive, which stated clearly in what situation the patient would request euthanasia, had been updated several months before the procedure to terminate her life was performed.

The independent SCEN physician who was consulted by the physician visited the patient two days before the procedure to terminate her life was performed, after she had been told about the patient’s situation by the physician and had examined her medical records. During the independent physician’s visit the patient was somnolent. The independent physician spoke with the patient’s family members, who confirmed and gave further details on her request as described in her advance directive. The independent physician could deduce from the patient’s demeanour that she was in the situation that she had stated in writing she never wanted to experience. There was no reasonable prospect of a return to a situation with sufficient dignity for the patient.

The independent physician concluded, in part on the basis of her interviews with the family and the medical staff treating the patient, and the medical record, including the advance directive, that the due care criteria had been complied with.

The committee noted the following as regards the request being voluntary and wellconsidered.

The physician was satisfied that the patient was now in the situation she had stated she did not want to experience. He wanted to keep his promise to the patient and end her suffering. On the basis of the advance directive, the conversations that the physician had previously had with the patient and the patient’s specific request, expressed a few days before the procedure to terminate her life was performed, the physician was  convinced the patient had made a voluntary and well-considered request.

The committee found that it had been established satisfactorily on the basis of the above information that the physician could be satisfied that the request was voluntary and  well-considered.

The report showed that the extent of the cerebral infarction meant that rehabilitation was no longer a possibility. In objective medical terms the patient’s suffering was without prospect of improvement. The physician, the independent physician and the attending geriatrician were satisfied that the patient was suffering unbearably. It was apparent from her demeanour and her facial expressions. It was also clear that all sense of purpose had gone from the patient’s life. The patient’s suffering matched what she had previously described orally and in writing as unbearable to her. The committee found that it had been established satisfactorily on the basis of the above information that the physician could be satisfied that the patient’s suffering was unbearable and without prospect of improvement.

The committee was satisfied that the physician could conclude that the requirement of informing the patient had been complied with, on the basis of the previous conversations he had had with her, her advance directive, her medical situation and the consultation with her children, and that there was no reasonable alternative for the patient’s situation.

The independent physician could not communicate with the patient. On the basis of the advance directive, patient records, the information given by the physicians and conversations with the patient’s family, the independent physician concluded that the patient’s euthanasia request was voluntary and well-considered. The independent physician found her suffering visibly and palpably unbearable and without prospect of improvement.
It was clear from the information given by the physician that he had discussed the current situation extensively with the patient beforehand. They had together reached the conclusion that there were no reasonable alternatives available for such a situation. The independent physician was satisfied that the due care criteria had been complied with.