2019-57, due care criteria not complied with

Non-straightforward notification, full report of findings, requirement of due medical care, leaving the patient.

The patient, a woman in her seventies, was diagnosed with stomach cancer nearly three months before her death. The patient’s condition was incurable. The patient experienced her suffering as unbearable. The physician was satisfied that this suffering was unbearable to her and with no prospect of improvement according to prevailing medical opinion. There were no alternative ways to alleviate the patient’s suffering that were acceptable to her. The patient had discussed euthanasia with the physician before. During those conversations it had become clear that the patient had made an explicit choice for assisted suicide because she wanted to maintain control over her own life, including its end.

The physician assisted her suicide by handing the patient Pentobarbital (a lethal substance) in 200ml of liquid, which she drank. After some time the physician left the patient’s house and went to her practice. She did this before she had established that the patient had died.

As regards the fact that the physician left the patient, the committee referred to the KNMG/KNMP ‘Guidelines for the Practice of Euthanasia and Physician-Assisted Suicide’, page 13 of which says: ‘During the euthanasia or assisted-suicide procedure, the physician must be and remain present. When the oral method is used (assisted suicide), this may take several hours.’ The Euthanasia Code 2018 is in line with this (see above).

In her oral explanation the physician acknowledged that she was familiar with the Guidelines. The independent physician had also mentioned them in his advisory report to the physician. Nevertheless, it was established that the physician had left the patient. She argued that a physician may, with good reason, deviate from the Guidelines. She had done so out of respect for the wish of the patient and her (adult) son to experience the last moments of her life without others present.

The committee noted first of all that it had no reason to doubt the physician’s account of the facts and circumstances, nor did it have reason to doubt the purity of her intentions. The physician wanted to respect the wish of the patient and her son. She recognised the risk of problems arising in the performance of the assisted-suicide procedure. She watched how the patient reacted to the ingestion of the Pentobarbital from the kitchen, from where she could see her. According to the physician, after five minutes the patient had become unresponsive; after 12 minutes no breathing was visible.

The physician did not confirm the patient’s death at that time. On the basis of her observations the patient did not think any problems were to be expected and she went to her practice. She checked whether the family members had her mobile phone number. The assisted suicide took place on her day off. She had no other work to do and waited for the phone call from the family member. The practice was a three-minute drive from the patient’s house. Immediately after receiving the message from the son, 12 minutes later, that his mother appeared to have died, the physician returned. She notified the pathologist of the course of events.

In its findings on case 2018-75, the committee held that in this respect the Euthanasia Code 2018 should be interpreted with caution. Although the facts and circumstances of that case were very different from the present case, the main considerations in those findings were followed here too. Assisted suicide by means of an ingested liquid carries certain risks. The procedure may take longer than when the euthanatics are injected directly into the bloodstream. There is also a risk that the patient, even one who is unconscious, will vomit up the liquid. This  requires immediate intervention and is why it is necessary to strictly follow the instruction that a patient must not be left before their death has been confirmed.

Moreover, the physician had an alternative that would allow her to fulfil the patient’s wish: she was able to await the outcome of the procedure in another room, out of sight of the patient and her son. Even though the physician’s practice was close by, and she had nothing else to do, there was insufficient certainty that she would be able to act immediately if problems occurred. The physician’s respect for the patient’s wish was compassionate, but formed insufficient reason to deviate from the Guidelines; it is the physician’s task as the expert to monitor any possible medical risks.

In the notification form the physician notified the pathologist and the RTE of the fact that she had left the patient. The physician thus facilitated review of her actions. When giving her oral explanation she showed herself to be aware of the possible risks. By her own account she later acted differently in a similar case, by staying in the direct vicinity of the patient. Nevertheless, the committee attaches great importance to compliance with the Guidelines and the reasoning behind them. There may be justifiable exceptions to the Guidelines, but this case is not one of them. The committee therefore found that the physician had not acted with due medical care in regard to the assisted-suicide procedure. The committee found that the physician had not acted in  accordance with the due care criteria laid down in section 2 (1) (f) of the Act.

The other due care criteria were complied with.