2017-38, due care criteria complied with

Non-straightforward notification, independent physician gives negative assessment, physician proceeds with euthanasia nonetheless.

The patient, a woman in her eighties, was suffering from severe fatigue, as well as wear and tear in several joints and osteoporosis. As a result, six months before her death, she broke her kneecap after a fall. The patient also suffered from age-related hearing loss (she was deaf in her right ear and had 60%hearing loss in her left ear). She had undergone two cataract operations. In the end she was blind in her left eye and her sight was impaired in her right eye. She also had mild cognitive impairments.

After her fall, the patient followed a rehabilitation programme in hospital and was allowed to go home after she had learnt to climb stairs again. She became increasingly frail, particularly after this period. Her general practitioner, the attending elderly-care specialist during the rehabilitation programme, and the independent geriatrician consulted by her general practitioner were of the opinion that the patient’s problems would not improve.

The patient’s suffering consisted of intense fatigue, increasing loss of hearing, loss of sight, dizziness and pain occurring every day in almost all her joints. She lost weight and became increasingly frail. She had difficulty walking and was unsteady on her feet. She was afraid of falling but refused to use a rollator, which she considered a loss of digniity. Her impaired hearing was an obstacle to her social interactions and due to her cognitive deterioration she could no longer pursue her hobbies the way she used to.

As a result there were few activities from which she could still derive satisfaction and self-respect. The patient, who had always been a very independent woman, found it terrible that she could no longer be the person she had always been. She suffered mostly from the prospect of even greater dependence. She had already had a taste of that when she broke her kneecap. She had hated the period in hospital and the rehabilitation process. She did not want to experience further debilitation. She longed for her life to end. 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. The physician and the general practitioner together decided to have further tests carried out by, among others, a vascular surgeon, a rheumatologist and an ear, nose and throat specialist. The physician also consulted an independent clinical geriatrician.

The latter suspected there was a ‘completed life issue’, possibly with depression contributing to the suffering. At the recommendation of this geriatrician, the patient had briefly taken antidepressants to improve her mood. This medication did not have a positive result, and caused too many side effects. The patient did not think she was depressed. It was suggested that she move into a more sheltered living environment, but she was utterly opposed to the idea. None of the physicians involved could see any viable alternative treatment options.

Although the independent physician established that the patient was having to make an increasing number of concessions and was experiencing very serious problems, he still felt that the issue was more a feeling of ‘completed life’ based on the patient’s experience of her disabilities rather than unbearable suffering. However, he believed that other medically related problems might emerge in the near future which would lead to unbearable suffering that was palpable to him. As it stood, he was unable to grasp the unbearable nature of the patient’s suffering sufficiently. The independent physician therefore concluded that the due care criteria had not been fulfilled.

In response to the independent physician’s negative assessment, the physician wrote on the model reporting form that she had initially been misled by the almost 90-year-old patient’s relatively youthful appearance, her well-kept house and her way with words. The patient always tried to keep up appearances. It had taken many conversations to convince the physician that the patient was suffering unbearably. As time went by, the medical dimension of her suffering became more evident.

Frailty and fatigue began to play an increasing role. The independent physician spoke with the patient only once, and compared the unbearable nature of her suffering with the suffering of other very elderly patients, and did not view it in light of this patient’s specific personality.

The physician spoke extensively with the independent physician. She understood the independent physician’s reasoning, but felt it would be unfair to the patient to wait until additional physical suffering occurred, for instance caused by a cerebral infarction (stroke).

The physician decided not to consult a second independent physician because the required consultation had already taken place and because she felt she was sufficiently able to substantiate her opinion and explain the difference between her view and that of the independent physician. The physician considered that a second independent physician would probably also be unable to penetrate the patient’s façade. The physician was convinced that the patient was suffering unbearably from a combination of conditions with a clear medical dimension, which she had difficulty dealing with due to her personality.

The committee noted that the physician was guided by the patient’s substantiated request and her own conviction, which developed over time, that the patient was indeed suffering unbearably without prospect of improvement. Physicians may disregard a negative assessment by the independent physician and proceed with euthanasia. According to the Act the physician is responsible, but will have to explain clearly why he or she disregarded the independent physician’s assessment.

The committee found that the physician explained extensively and convincingly in her reports why she became convinced that the patient’s suffering was unbearable to her and without prospect of improvement, and that there were no reasonable alternatives to reduce the suffering. In view of the above facts and circumstances, the committee found that the due care criteria had been complied with in this case.