2018-42, due care criteria not complied with

Non-straightforward notification, particular caution to be exercised with psychiatric patients, consulting an independent psychiatrist, treatment may be refused.

The patient, a woman in her seventies, had suffered from psychiatric disorders since she was a teenager. Her symptoms were diagnosed as schizoaffective disorder (a psychiatric disorder involving psychoses and mood-related disorders). She experienced periods of severe depression and occasional psychotic episodes. She had made a number of suicide attempts and had been hospitalised several times. The patient had, over time, undergone extensive treatments with medication and psychotherapy for her psychiatric disorders. However, these had not led to improvement in her psychological condition.

About five months before her death, the patient was diagnosed with an aortic aneurysm and needed urgent surgery. She was also found to have lung cancer. The patient refused treatment because she was suffering unbearably without prospect of improvement due to her psychiatric disorders. She had been wanting to die for years. She saw the aortic aneurysm and lung cancer diagnoses as a welcome opportunity to be released from her difficult life.

Her general practitioner did not perform euthanasia for reasons of principle and asked the physician (also a general practitioner) if he would be willing to take over the euthanasia procedure. The patient’s first conversation with the physician about euthanasia took place about two months before her death.

Around two and a half weeks before her death, the patient asked the physician to actually perform the procedure to terminate her life. The physician consulted by phone with a psychiatrist at the mental health service where the patient was being treated. This psychiatrist believed that the patient had a realistic wish for euthanasia on the grounds of severe, untreatable psychiatric suffering.

The physician consulted an independent physician who was also a SCEN physician (not a psychiatrist). The independent physician saw the patient about a week and a half before her death. He concluded that the due care criteria had not yet been complied with. In his eyes, the patient had not yet actually made a specific request for euthanasia, nor was she suffering unbearably. The independent physician asked the physician to contact him if these circumstances changed.

Two days before the patient’s death the independent physician established, on the basis of phone conversations with the physician, that the patient’s situation had changed. She had requested euthanasia in the very near future. The independent physician was satisfied that the request was clearly based on a combination of severe chronic psychiatric disorders that could no longer be treated and recently diagnosed, possibly life-threatening somatic conditions. He concluded that the due care criteria had now been complied with.

The committee found the case file submitted to be too limited and asked the physician for a further written explanation. This explanation provided the committee with insufficient clarity, so the physician was invited for an interview. The committee’s questions mainly concerned the patient’s case file, the physician’s conviction that the patient’s request was voluntary and well considered and that she was suffering unbearably with no prospect of improvement, and the fact that an independent psychiatrist had not been consulted.

The physician answered that the digital case file was very limited. He had obtained additional information by talking to the general practitioner and the patient’s husband. He had also phoned the mental health service where the patient was being treated. It was not entirely clear who was treating her, because at that time cases were being handed over from one psychiatrist to another. In addition, there was by that stage very little contact between the mental health service and the patient.

Asked by the committee whether the patient was still able to refuse treatment in a well-considered manner, the physician answered that he had thought carefully about this. At all times he had been satisfied that the patient was decisionally competent. There was one moment when he had doubts, and that was when he read the independent physician’s first report and did not understand it completely.

The independent physician believed that the patient was not yet suffering unbearably because she had not yet expressed an actual request. For a moment, he had a feeling that the patient was being manipulative. He went to see her and also contacted the independent physician. During her conversation with the physician, the patient expressed great disappointment at the independent physician’s negative recommendation.

The physician was able to discuss with the patient what her suffering entailed. Every day was one of terrible suffering; she experienced her life as hell. The physician did not feel the independent physician’s report supported him sufficiently and therefore did not want to proceed with euthanasia in that situation. Once the patient had clearly and specifically requested euthanasia in the very near future, the physician consulted the independent physician by phone. The independent physician was satisfied that the due care criteria had now been complied with.

As regards consulting an independent psychiatrist, the physician said it had not occurred to him to consult such a person. After all, with her very long case history the patient had been treated by many psychiatrists over the years without any significant result. He did consult several colleagues. In hindsight the physician acknowledged that he did not act entirely correctly. Although he had thought very carefully about whether the due care criteria had been complied with and was fully satisfied that they had, it was now clear to him that he had not exercised the particular caution that is required in cases involving suffering caused by a psychiatric disorder. He should have been more diligent in that respect and have consulted an independent psychiatrist.

The committee noted that physicians must exercise particular caution when dealing with a euthanasia request from a patient suffering from a psychiatric disorder (as follows from the Supreme Court judgment in the 1994 Chabot case). Exercising such caution involves consulting an independent psychiatrist in addition to the regular independent physician.

The independent psychiatrist always assesses the voluntary and well-considered nature of the euthanasia request (due care criterion a). The possibility that a psychiatric disorder has impaired the patient’s powers of judgment must be ruled out. Furthermore, a patient cannot make a well-considered decision without a sufficient understanding of the disease, diagnoses, prognoses and treatment options. For that reason the patient must be given sufficient information about their situation and prognosis (due care criterion c).

As regards suffering with no prospect of improvement (due care criterion b) and the absence of a reasonable alternative (due care criterion d), the possibility of other treatment options for the patient must be carefully explored by the independent psychiatrist (see the Euthanasia Code 2018, pages 42 to 44). This does not rule out the possibility that in some cases the SCEN physician and the independent psychiatrist are the same person.

The committee realised that, as a result of the circumstances, the physician was faced with a difficult task. It respected the fact that the physician was willing to take over this complicated case from a colleague. Nonetheless the committee found that the notes submitted by the physician, the physician’s further written explanation and the interview with the physician showed that the physician did not exercise the particular caution that may be expected in a case involving a euthanasia request by a patient with a psychiatric disorder.

By not consulting an independent expert, who would have assessed the above-mentioned due care criteria independently, the physician was unable to argue plausibly that the due care criteria laid down in section 2 (1) (a) (b) (c) and (d) of the Act had been complied with. The physician did not give a convincing reason why he had neglected to consult an extra expert. In addition there had been little contact with the attending psychiatrist.

The physician consulted one other, independent physician, who saw the patient and gave a written opinion on whether the due care criteria had been complied with. The physician thus complied with the due care criterion referred in section 2 (1) (e) of the Act. However, the independent physician consulted by the physician lacked the necessary expertise in this type of case to be able to assess due care criteria (a) to (d) in the Act independently.

The committee also noted that the independent physician did not advise the physician adequately. It would have made sense for the independent physician to point out to the physician that, given his lack of specific expertise and the patient’s long case history, an independent psychiatrist needed to be involved.

The committee found that the physician had not acted in accordance with all the due care criteria.