2015-29, general practitioner, cancer, not acted in accordance with the due care criteria
KEYPOINTS: KNMG/KNMP Guideline ‘Performing euthanasia and assisted suicide procedures’, adequate assessment of depth of coma
When performing euthanasia, the physician deviated from the KNMG/KNMP Guideline ‘Performing euthanasia and assisted suicide procedures’ of August 2012. Instead of administering 1000mg of propofol to induce a coma, he stopped after having administered 200mg because he thought the patient was in a coma. As the physician had not checked the depth of the coma adequately, it could not be ruled out that the patient was in an insufficiently deep coma and that she might have perceived the effects of the muscle relaxant. In view of the above, the physician did not perform euthanasia with due medical care.
The physician performed the termination of life on request on a patient who had been diagnosed with acute myeloid leukaemia by intravenously administering 200mg of propofol and 100mg of rocuronium, after which the patient died.
The physician stated in a written explanation that he did not perform any tests to check the depth of the coma. He thought that it would have been indelicate and ethically improper to carry out such tests in the presence of the patient’s husband and four children. He thought it was unnecessary and ethically improper to administer more than 200mg of propofol to a patient who was clearly in a deep coma. He also did not want to further affect the fragile intravenous access site by administering yet more of an irritant fluid.
The committee invited the physician to provide further information in person. The committee asked him why, when performing euthanasia, he deviated from the KNMG/KNMP Guideline ‘Performing euthanasia and assisted suicide procedures’ of August 2012 and administered 200mg of propofol instead of the prescribed 1000mg.
The physician answered that he was satisfied that the patient was already in a deep coma after he had administered 200mg of propofol and that it was unnecessary to administer any more. The physician said it was his practice to continue administering propofol for as long as he thought it necessary. He said that while performing the procedure he would assess from step to step whether it was necessary to administer more, and when he thought the purpose had been achieved, he would stop administering the propofol.
When questioned on the matter, the physician said that he thought it was unethical to inject too large a dosage. Another factor in this particular case, the physician said, was that the access site to the vein was very fragile, which in his opinion meant that injecting more propofol might make it difficult to administer the rocuronium.
According to the physician the patient was in a deep coma because she was in a deep sleep, her respiration was slow and her pulse was weak. Verbal communication with the patient was impossible. When questioned on the matter, the physician said that he had not checked the patient’s protective reflexes, such as the eyelash reflex and/or the corneal reflex, or her response to strong pain stimuli such as pressure on the nail bed or pinching the trapezius muscle, but instead applied a light pain stimulus to the patient’s hand, to which she did not respond. The physician stated that he had not noted this in his response to earlier written questions from the committee, but that he had indeed applied the pain stimulus to the hand. He conducted no further tests. The reason he gave was that he would have to stand up and walk round the bed, which he felt
would be distressing for the family.
The committee noted the following in connection with the performance of the procedure to terminate the patient’s life. On the basis of the medical records and the interview with the physician, it became clear to the committee that the physician administered 200mg of propofol instead of the 1000mg recommended in the KNMG/KNMP’s Guideline ‘Performing euthanasia and assisted suicide procedures’ of August 2012. This means that the dosage of the coma-inducing substance used was too low. The committee would point out that the use of a coma-inducing substance recommended in the Guideline in the correct dosage is crucial in order to ensure that the patient cannot perceive the effects of the muscle relaxant (death by asphyxiation). The Guideline therefore prescribes that before the muscle relaxant is administered, it must be established that the patient is in a medically induced coma.
It is apparent from the written response to earlier questions from the committee that, after administering the 200mg of propofol, the physician established that the patient was in a deep coma; her respiration was infrequent and rattled a little. The physician had conducted no further tests to check the depth of the coma. As the physician stated in his oral account that he applied a light pain stimulus to the hand, but omitted that information in the written response to earlier questions from the committee, the two statements do not correspond. In the committee’s opinion, even if the physician did apply a light pain stimulus to the patient’s hand, that did not mean he adequately assessed the depth of the coma, as it has been established that he did not check for the presence of protective reflexes, such as the eyelash reflex, or for a response to a pain stimulus, such as pinching of the nail bed or the trapezius muscle. The committee therefore concluded that the physician did not adequately assess the depth of the coma.
Checking the depth of the coma properly was particularly important in this case, because the physician administered less than the recommended dosage of propofol. According to the committee, it could not be ruled out that the patient was inan insufficiently deep coma and that she might have perceived the effects of the muscle relaxant, i.e. death by asphyxiation. On the basis of the above facts, considered as a whole, the committee found that the physician did not exercise due medical care in terminating the patient’s life. The physician’s explanation that he did not administer the full dosage of propofol due to the state of the venous access site does not detract from that. The fact that the physician administered too little rocuronium played no role in this finding.