2016-21, elderly-care specialist, neurological disorders, not acted in accordance with the due care criteria

KEY POINTS: no sufficiently informed assessment of whether the patient’s suffering was without prospect of improvement, physician disregarded the neurologist’s advice and the psychiatrist’s assessment without further enquiry

The patient, a man in his fifties, was diagnosed with Parkinson’s disease four years before his death. He was treated with medication and because he was having difficulty coping with the disease, he received psychotherapy and other treatments at various stages of his illness. He twice underwent deep brain stimulation (electrodes implanted in the brain send electrical impulses to suppress specific symptoms); the second procedure took place around five months before his death. None of this achieved the desired result.

After the last treatment, the patient’s symptoms worsened. This caused tension and feelings of anxiety and helplessness. The patient experienced his suffering as without prospect of improvement and asked his physician for euthanasia.

At the physician’s request, the patient was seen by a psychiatrist who found him to be decisionally competent. In the psychiatrist’s opinion, there was a psychological aspect, in addition to the Parkinson’s disease, that had not yet been treated sufficiently. The psychiatrist recommended a trial course of medication for depression.
The patient stopped taking the medication after a few days, as he felt it aggravated his symptoms. He did not want any more psychotherapy to alleviate the symptoms of Parkinson’s disease, which could no longer be treated and were increasing.

The attending neurologist found that the patient had a mild form of Parkinson’s disease, in which the tremor (shaking movements in the limbs) was largely determined by emotional factors. He was also of the opinion that the man’s fear of the future was the dominant factor. The neurologist thought that adequate treatment of this fear and the underlying mood disorder was the appropriate course of action. The neurologist was unable to support the patient’s request for euthanasia on the grounds of the severity of his Parkinson’s disease.
He also considered that, as he was unable to support the request from a neurological point of view and the patient wished no further psychiatric treatment, it was impossible to properly assess whether the man’s suffering was without prospect of improvement.

The notifying physician was satisfied that this suffering was unbearable to the patient and with no prospect of improvement according to prevailing medical opinion; he performed euthanasia.

The committee had questions about the absence of a reasonable alternative. The physician was therefore first asked to give a written explanation, later followed by an oral one.
The physician was of the opinion that, given the patient’s medical history, personality and life history, they had nothing more to offer him. When asked by the committee whether he was satisfied that if it had been possible to treat the stress suffered by the patient, the symptoms of Parkinson’s disease would have become milder and therefore the tremors would also lessen, the physician replied that he was not satisfied that that was the case.

The committee referred to the psychiatrist’s assessment (that the psychological component had been treated insufficiently) and the neurologist’s assessment (that it was a mild form of Parkinson’s disease in which treatable psychological factors played a role) and pointed out that the process had taken very little time (the physician had talked with the man twice in eight days). The committee noted that if the process is short it attaches great importance to intensive communication, not just between the physician and the patient, but also between the physician and other persons involved. In such a case the physician must do everything that is reasonably possible to obtain all the information that may be relevant.
The committee was of the opinion that the physician should not have disregarded the neurologist’s advice and the psychiatrist’s opinion without further enquiry. He should have consulted with them or with another specialist who was an expert in the field. Particularly in view of the speed at which the process was conducted and the fact that the physician had only spoken twice with the patient, the physician should have used such consultation to assess his own views against those of the specialists.

The committee therefore found that the physician had not plausibly argued that he was reasonably able to conclude that the patient was suffering unbearably without prospect of improvement or that there were no reasonable alternatives that could alleviate his suffering.