2019-121, due care criteria complied with

Publication | 01-01-2019

The patient, a man in his sixties, suffered from recurring depressions andnarcissistic and antisocial personality disorders. (A narcissistic personality disorder has two aspects. It is characterised on the one hand by an inflated sense of self-importance and a deep need for admiration, on the other by an extreme sense of inferiority and insecurity. People with an antisocial personality disorder find it difficult to adhere to rules and take account of other people. It can be accompanied by irritability, aggression, impulsiveness and indifference.) The patient also suffered from a serious alcohol use disorder. The patient was treated over many years with both medication and psychotherapy. He was admitted to an institution on several occasions. In spite of this, his condition continued to deteriorate. He had lived since 2010 in sheltered housing. In 2016 he began Function Assertive Community Treatment – Mentalisation-Based Treatment (FACT-MBT), which focuses on making a person aware of their actions, feelings and behaviour, especially in terms of how they interact with other people. The patient stopped this treatment about six months before his death because it was not yielding sufficient results in terms of changing his wellbeing.

At the physician’s request, an independent geriatric psychiatrist assessed the scope for any other realistic treatment options for the patient. The geriatric psychiatrist spoke to the patient on three occasions. He confirmed the earlier diagnoses, but also found that the patient exhibited autistic tendencies (autism is a disorder characterised by impairments in the area of social interaction and verbal and non-verbal communication, and by restricted behaviour patterns with a great deal of repetition or fixed habits). The geriatric psychiatrist therefore took the view that change-oriented treatment of the patient’s personality disorders would  ot lead to further improvement but was likely to ask too much of him. The patient recognised his impairments but clearly indicated that he lacked the motivation and saw no possibilities to change and adapt. The geriatric psychiatrist therefore saw no further realistic alternative treatment options.

The patient’s suffering consisted of deep mistrust of other people. This meant that he could not establish any meaningful contact with others. Although he could establish superficial contact, as soon as he was alone he was assailed by doubt as to the sincerity of the other person. Then he felt a great void within himself. He also felt sorrow at the harm that his behaviour had caused in his personal relations. This gave rise to a feeling of existential loneliness which he could not escape and could only suppress through alcohol. People shunned him when he was under the influence of alcohol, which in turn confirmed his suspicions and his self-image. He repeatedly reverted to behaviour that made people turn their backs on him. As a result he was despondent. The patient experienced his suffering as unbearable. The physician was satisfied that this suffering was unbearable to the patient and with no prospect of improvement according to prevailing medical opinion. There were no alternative ways to alleviate his suffering that were acceptable to the patient.

The patient first spoke with the physician about euthanasia in August 2018 and they subsequently talked at length on about 20 occasions. During each conversation the patient asked the physician to actually perform the procedure to terminate his life. He also regularly repeated his request for euthanasia to other practitioners who were treating him.

The geriatric psychiatrist referred to above also examined the patient’s decisional competence. He established that the patient was capable of fully grasping the implications of his request. Although his alcohol disorder was serious, the patient was capable of abstaining when he had appointments with health professionals. The geriatric psychiatrist considered the patient to be decisionally competent regarding his request for euthanasia.

The physician found that the patient’s request was persistent and consistent. She considered him fully decisionally incompetent. The physician concluded that the request was voluntary and well considered. The physician consulted an independent physician who was also a SCEN physician and a psychiatrist. The independent physician saw the patient about six weeks before the termination of life was performed, after he had been informed of the patient’s situation by the physician and had examined his medical records. The independent physician found that there was no prospect of improvement in the patient’s psychiatric problems. He reached this conclusion on the basis of the chronic nature of the patient’s condition and the lack of an effective treatment. The independent physician also considered the patient to be decisionally competent regarding his request for euthanasia.

The committee noted that, in the event that a request for euthanasia is prompted by suffering resulting from a psychiatric disorder, the physician must exercise particular caution. Such caution must be exercised especially when assessing the voluntary and well-considered nature of the request, the absence of any prospect of improvement, and the lack of a reasonable alternative. If contact with both a psychiatrist and an independent physician places an unacceptable burden on the patient, an independent psychiatrist or a SCEN physician who is also psychiatrist will have to provide specific expertise.

On the basis of all the information submitted by the physician, the committee
found that she had indeed exercised particular caution in the case in question. It took into account the fact that the physician had acted in accordance with the guidelines applicable to her profession. The committee was also mindful that the physician consulted an independent psychiatrist, who concluded that the patient was decisionally competent in relation to his request for euthanasia, that the patient’s suffering was without prospect of improvement and that there were no reasonable treatment options left. 

The independent physician confirmed the physician’s opinion that, after a long period in which the patient had undergone treatment without any lasting improvement, it could be concluded that there were no longer any realistic alternatives for the patient, and that his unbearable suffering was therefore without prospect of improvement. In addition, the independent physician confirmed the physician’s conclusion that the patient’s wish was a longstanding one and that his request was voluntary and well-considered.

The committee found that the physician had acted in accordance with
the due care criteria.