2019-90, due care criteria complied with

Straightforward notification, full report of findings, request, dementia, doubt about decisional competence, End-of-Life Clinic.

The patient, a man in his 80s, had suffered from a variety of conditions for many years including visual impairment, diabetes mellitus, osteoporosis, osteoarthritis and complete incontinence. About two years before his death, the patient was diagnosed with Alzheimer’s disease. The patient’s condition was incurable. He could only be treated palliatively. Because of his care requirements, the patient was admitted to a nursing home about nine months before his death.

The patient’s suffering consisted of increasing weakness, loss of strength, balance problems and incontinence, as well as his general decline. He could no longer stand or walk and needed to be lifted out of bed using a hoist. He could not get out and about, which made him deeply unhappy. He understood that he needed to live apart from his wife because of his care requirements, but it caused him considerable distress. He had always been an active man, a real doer. He was suffering due to chronic pain throughout his body, his near-inability to function, his complete dependence and the lack of any prospect of improvement in his situation. The fact that he sometimes became disoriented and had difficulty remembering things and finding the right words also caused him suffering. Essentially, however, his suffering stemmed from his physical decline and loss of independence. 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.

The patient had discussed euthanasia with his general practitioner before. Because his general practitioner considered the patient’s situation to be too complex, he referred him to the End-of-Life Clinic. More than two months before his death, the patient asked the physician to actually perform the procedure to terminate his life. The patient repeated his request to the physician during the four subsequent conversations. The physician concluded that the request was voluntary and well

The physician asked the patient’s attending psychiatrist for medical information. The latter concluded that the patient’s cognitive impairments due to dementia were so far advanced that he should be considered decisionally incompetent with regard to his request. The attending psychiatrist provided no further reasons in support of her position. The physician, an elderly-care specialist, did not share this conclusion. She asked the independent physician she consulted, who was also an elderly-care specialist, to devote extra attention to the patient’s decisional competence with regard to his request for euthanasia. The independent physician saw the patient about two months before his death. He took the view that the patient was well able to appreciate the consequences of requesting the termination of his life and to give the reasons for his decision. The independent physician considered the patient to be decisionally competent regarding his request. Nevertheless, he advised the physician to have an independent psychiatrist assess the patient’s decisional competence, in light of the opinion given by the attending psychiatrist.

Following an examination, the independent psychiatrist concluded that the patient was not suffering from depression. With regard to the question of whether the patient was decisionally competent to make his request, the independent psychiatrist concurred with the findings and conclusions of the independent physician and the physician. He considered that, despite suffering from Alzheimer’s disease, the patient was quite capable of conveying his point of view and considerations concerning his request for euthanasia. He considered him to be decisionally competent regarding his request.

The committee noted that in the case of a patient with early-stage dementia the physician is called upon to exercise particular caution in ascertaining whether the statutory due care criteria have been satisfied, especially the criteria that the request should be voluntary and well considered and that the patient’s suffering must be unbearable.

On the basis of information submitted by the physician, the committee found that the physician had indeed exercised particular caution. The physician – an elderly-care specialist – had no doubt as to the decisional competence of this patient with early-stage dementia. When the attending psychiatrist concluded that the patient was not decisionally competent with regard to his request, the physician reflected on her own conclusions and how she had intended to proceed. She both asked the independent physician to pay extra attention to the patient’s decisional competence and consulted an additional independent expert to assess that competence. Both considered him to be decisionally competent regarding his request for euthanasia. By acting as she did, the physician exercised particular caution.

In reaching its opinion, the committee took account of the fact that the physician enjoys a certain degree of discretion. The attending psychiatrist failed to provide  reasons in support of her opinion that the patient was not decisionally competent. The physician, the SCEN physician and the independent psychiatrist found that the patient was decisionally competent and provided arguments and observations in support of their conclusions. In light of this the committee found that the physician,
using the discretion accorded to her, 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.