2019-126, due care criteria complied with

Publication | 01-01-2019

The patient, a man in his twenties, had had behavioural problems and anger management issues since he was 12. For this reason he had been placed in various youth care institutions and foster families since he was 15. Eventually, in 2011, he was diagnosed with borderline personality disorder characterised by antisocial tendencies. (Borderline personality disorder is a mental disorder whereby the patient experiences severe mood swings, has difficulty forming stable relationships and is often afraid of being abandoned. Antisocial tendencies means that the patient finds it very difficult to adhere to rules and consider other people.) Other psychiatric disorders were also diagnosed, such as ADHD (a concentration disorder) with features of autism. (Autism is a disorder characterised by impairments in the areas of social interaction and verbal and non-verbal communication, and by restricted behaviour patterns with a great deal of repetition or fixed habits). He also suffered from obsessive compulsive disorder (intrusive anxious and unpleasant thoughts that are difficult to suppress), pyromania (an irresistible impulse to start fires) and problematic substance use. He was also thought to be suffering from acquired brain injury. From the age of 13, the patient attempted suicide on three occasions. He often inflicted serious self-harm.

From adolescence the patient was treated extensively with both medication and psychotherapy. He had spent a long period in a forensic ward under a court order for committal to a mental healthcare institution pursuant to the Psychiatric Hospitals (Committals) Act. Despite long-term treatment in the institution and some initial progress, in the past five years the patient’s situation had deteriorated in comparison with the situation on admission. Social rehabilitation had also proved impossible.

The attending psychiatrist suspected psychological treatment would have no chance of success. Schema therapy (a type of psychotherapy that helps the patient to understand and change long-standing patterns of behaviour) had had no effect on the patient. The patient no longer wanted to receive any treatment. The attending psychiatrist thought that the suspected brain injury played a part in that respect. She thought the patient’s chances of changing his behaviour were very slim.

Around two months before the patient’s death the physician consulted an independent psychiatrist. She asked him to review the diagnosis and possible treatment options for the patient. The psychiatrist’s findings matched those of the others who had been treating the patient. As the patient had no desire whatsoever to receive treatment, there was no way of starting psychotherapy. In any case, given the patient’s long treatment history and the very limited results achieved, it was unlikely that psychotherapy would have much effect in terms of behavioural change. The independent psychiatrist, too, thought that the patient’s ability to change his behaviour was very limited. The independent psychiatrist concluded that there were no realistic treatment options left for the patient. The patient’s condition was incurable.

The patient was suffering from an urge to carry out impulsive acts that could not be managed. These acts included starting fires, self-harm and acting out (when a person acts destructively and aggressively without taking account of the negative consequences). In this way he was trying to cope with mounting internal tensions. The thoughts about starting fires and self-harming occupied him all day long. He was barely able to suppress these thoughts, and as a result he self-harmed constantly. The patient knew that as a result of his disorders he would never be able to function normally in society. He therefore saw his future as unliveable. 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.

Since 2015 the patient had spoken with several attending physicians about euthanasia. In that same year he registered with the End-of-Life Clinic (SLK) for the first time. Shortly after, he cancelled his registration due to personal circumstances. Shortly afterwards those personal circumstances changed, and from that moment his wish for euthanasia remained undiminished in the years that followed. He discussed it repeatedly with those treating him. The patient’s attending psychiatrist refused to carry out his request, for reasons that were not disclosed. Moreover, she was not entirely convinced that the patient’s suffering was without prospect of improvement. For that reason, the patient registered with the SLK again in April 2018.

Over a period of six months, the physician spoke extensively on four occasions with the patient about his request. During each of those conversations the patient asked the physician to actually perform the procedure to terminate his life.

On the basis of the conversations the physician had with the patient, she considered him decisionally competent in relation to his request. He was able to clearly explain the reasons for his decision and the consequences of his request. The physician concluded that the request was voluntary and well considered. The aforementioned independent psychiatrist also considered the patient to be decisionally competent regarding his request.

The independent SCEN physician consulted by the physician was satisfied that the patient was suffering unbearably from his constant thoughts about starting fires and self-harming. As a result the patient would never be able to participate in society in a normal manner. He established that, in view of the patient’s treatment history, the independent psychiatrist’s report, the patient’s character and his inability to make something of his life, there were no reasonable alternatives for the patient. The independent physician concluded that the patient had had a consistent wish for euthanasia for many years and he considered him decisionally competent in relation to his request.

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. Particular 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. The specific expertise of an independent psychiatrist is required in such cases (Euthanasia Code 2018, pp. 42-43).

On the basis of all the information provided by the physician, the committee found that in the present case the physician exercised particular caution, among other things because she consulted an independent psychiatrist, who concluded that the patient was decisionally competent in relation to his request for euthanasia, his suffering was without prospect of improvement and there were no reasonable treatment options left. The independent physician confirmed the physician’s assessment that the due care criteria had been complied with.

The committee reflected on the fact that the patient had previously been confined under criminal law and at the time of his request for euthanasia had been placed in a secure ward subject to a temporary court order under the Psychiatric Hospitals (Committals) Act. The committee noted the following in this respect. A stay in such a setting, in which the patient is deprived of his liberty by the state and is subject to legal status rules relating to (involuntary) treatment can, in the committee’s opinion, have an influence on external voluntariness, whether the suffering is unbearable and/or without prospect of improvement, and/or the absence of reasonable alternatives.

It became clear to the committee from the documents that the temporary order was intended to provide the patient with a safe place to stay. This patient, for whom social rehabilitation had proved impossible, could only function in an involuntary setting. It was also clear to the committee that extension of the temporary order would mean the patient had a place to stay if he changed his mind about euthanasia. The committee therefore considered it plausible that the involuntary setting in which the patient was staying did not require further review.

The other due care criteria were also fulfilled in the committee’s view.