2019-22, due care criteria complied with

Non-straightforward notification, patient in secure psychiatric institution, combination of somatic and psychiatric disorders, End-of-Life Clinic

The patient, a man in his seventies, was diagnosed with an autism spectrum disorder (a disorder characterised by impairments in the area of social interaction and verbal and non-verbal communication, and by a restricted behaviour pattern with a great deal of repetition or fixed habits) and with obsessive-compulsive disorder (intrusive anxious and unpleasant thoughts that are difficult to suppress). In addition he suffered from a lung disease (chronic obstructive pulmonary disease; COPD), intermittent claudication and diabetes mellitus. From his adolescence onwards, the patient had been treated extensively with medication and psychotherapy. Over the years he had attempted suicide on several occasions.

After severe dysregulation of his condition more than 20 years before his death, the patient had been placed in a long-stay ward in a secure psychiatric institution (a treatment clinic where people are admitted who have committed a serious crime for which they cannot be held – fully – responsible due to a personality disorder and/or a serious psychiatric disorder. Patients who cannot be cured and who continue to pose a danger remain in a long-stay ward for the rest of their lives.). The patient was no longer receiving active treatment; his condition was in fact now untreatable. Several years before the patient’s death, the Centre for Consultation and Expertise strongly advised against transferring the patient to a specialised clinic for people with autism. There was nothing that he could realistically achieve there. Admitting him to a regular mental health institution was not seen as a genuine option either, because he required a high level of security. This was not because he was a flight risk but because he had little to no control over his natural urges, whichcould lead to serious consequences for other people.

At the physician’s request, around four months before the patient’s death an independent psychiatrist reviewed the diagnosis and any possible treatment options for the patient. The independent psychiatrist agreed with the diagnosis that was apparent from the documents. The patient was not suffering from a mood disorder, depression or mania (periods of elevated mood, such as elation, anger or hyperactivity). Nor were there any indications of dementia. The psychiatrist established that the patient was suffering from a long-term psychiatric disorder (an unchanging chronic defect state). He, too, thought that it was not a good idea to admit the patient to a specialised treatment clinic for autism. This would carry a large risk of dysregulation (upsetting the existing equilibrium). Impulsive suicide could then not be ruled out. The independent psychiatrist concluded that the patient could no longer be treated. His condition was incurable.

The patient was suffering from his inability to participate in society. He had always felt out of place in the world and had wanted euthanasia for years. He constantly had compulsive thoughts. The patient was unable to live among other people, as he quickly became overstimulated. As a result he lived in isolation in the clinic and did not take part in group activities. Due to exhaustion, he could also no longer carry out household tasks. The patient felt the world was too complicated for him. In addition, as he grew older various physical problems had developed. His legs hurt and he quickly became short of breath. As a result of these physical problems he was barely able to function. He could only take small, shuffling steps, was tired all the time and wanted to stay in bed every day. He felt completely off-balance, both physically and mentally.

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 had discussed euthanasia before with his attending psychiatrist in the clinic where he was staying. The attending psychiatrist supported the patient’s request, but due to the clinic’s protocol was not allowed to carry it out.

For this reason, the patient contacted the End-of-Life Clinic (SLK), over a year before his death. The physician spoke extensively on five occasions with the patient about his request. During their first conversation, the patient immediately asked the physician to actually perform the procedure to terminate his life. As they had to wait for a decision from the Ministry of Justice and Security as to whether the patient was permitted to enter into a euthanasia process, the first conversation was around eight months before the patient’s death. He repeated his request to the physician during many subsequent conversations.

The aforementioned independent psychiatrist considered the patient to be decisionally competent regarding his request. During the physician’s conversations with the patient, it was clear that the patient was well aware of what his request entailed. The physician considered him to be decisionally competent regarding his request for euthanasia. He concluded that the request was voluntary and well considered.

The physician consulted an independent physician who was also a SCEN physician. The independent physician was satisfied that the patient was suffering unbearably as a result of multiple geriatric syndromes, in combination with an unchanging chronic defect state. The independent physician considered the patient to be decisionally competent.

The committee noted the following in this case.
The patient had been detained under criminal law in a custodial psychiatric clinic. The committee wished to determine whether his stay in a long-stay ward and the reason he remained there might in one way or another have influenced the voluntary and well-considered nature of the request.

The patient had a realistic perception and understanding of his illness and he felt the long-stay ward was the best place for him to be. With the help of his attending psychiatrist, the patient had turned to the End-of-Life Clinic (SLK). The committee concluded from this that the patient’s wish was well considered and consistent. It was plausible that the patient’s request was voluntary, as the physician, the attending psychiatrist and the independent psychiatrist considered him to be decisionally competent regarding his request. In view of the above facts and circumstances, the committee found that the physician could be satisfied that the patient’s request was voluntary and well considered.

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