2014-47, general practitioner, other conditions, unbearable suffering without prospect of improvement, independent assessment

Publication | 01-01-2014

In 2014, as in 2013 (see 2013 annual report, case 9), the committees received several notifications of cases in which euthanasia had been performed simultaneously on a couple. In all these cases, the committee found that the due care criteria had been complied with. For information on voluntary and well-considered requests see page 11 of the Code of Practice, on unbearable suffering without prospect of improvement see page 13 and on the independent physician see page 16.

A married couple requested simultaneous assisted suicide. The female patient had substantial medical problems and physical disabilities. She was dependent on care, which in the past had always been provided by her husband. He too had severe health problems and would have euthanasia performed soon. The physician was able to conclude that in view of the patient’s past life, her close relationship with her husband and the lack of a social network of her own, the prospect for this patient of a life in which she would be dependent on other people for her physical care, probably in a nursing home, meant unbearable suffering without prospect of improvement. The suffering had a predominantly medical dimension.

In the event of simultaneous euthanasia requests by a couple, the physician must consider carefully whether it is preferable to consult one independent physician for both partners or a separate independent physician for each. If one independent physician is asked to assess both requests, that physician will have to be extra alert to the question of whether he is able to form an independent judgment in both cases. In principle, the independent physician will have to speak with each partner separately. In this particular case the physician consulted the same independent physician for both euthanasia requests. The independent physician believed he was capable of forming an independent judgment in each case. However, he did not speak to the patient and her husband separately. Particularly in view of the patient’s dependence on her husband, it would have been better if the independent physician had done so. Nevertheless, partly in view of the findings of a psychiatrist consulted on the matter, there is no reason to doubt the accuracy of the independent physician’s conclusions.

* This concerns two separate notifications, which were reviewed separately. The finding described here concerns only the notification of the woman’s assisted suicide.

More than 25 years before her death, the patient, a woman in her eighties, had suffered a brainstem stroke. Despite lengthy rehabilitation, she continued to have difficulty walking, even when using a rollator. Five years before her death, the patient was diagnosed with osteoporosis, with various vertebral compression fractures, severe arthrosis of the knee and a rotator cuff tear in the right shoulder. As a result, walking became even more difficult. Two years before her death, a heart valve was found to be defective and she was thought to have aortic sclerosis. Over the years, the patient suffered several TIAs and lost more and more weight. Eventually she only weighed 45kg. The patient also suffered from  hypertension and presbycusis. Her condition was incurable. She could only be treated palliatively.

In addition to her having to live with her many medical problems and her physical disabilities, the patient suffered because of the knowledge that she was not self-reliant and that when her husband died (he had severe health problems and was to have euthanasia performed soon), she would be dependent on other people and would probably have to go into a nursing home. For many years, partly due to residual symptoms of the brainstem stroke,  the patient had to some extent been  dependent on her husband’s care and had developed a symbiotic relationship with him. The patient had still been living with her parents when they married and had lived abroad with her husband for a long time. They had always done everything together. One time when she had to spend a couple of weeks alone, which had been necessary in connection with her husband’s job, she had found it disastrous. She did not want to go through that again. A life without her husband, in which she would be dependent on care provided by other people, was inconceivable for her. The patient, who had no children and had not built up her own social network, experienced her current and expected suffering as unbearable. The patient had on several occasions discussed her wish for euthanasia in the event of her husband’s death with the physician.

One day before her death, the patient asked the physician to actually perform the procedure to terminate her life, almost immediately after her husband had made the same request for himself. The patient later repeated her request.

At the request of the physician a psychiatrist assessed whether the patient’s request was influenced by a psychiatric disorder or dementia and whether she was decisionally competent with regard to her request. The psychiatrist established that the patient’s wish for euthanasia was palpable and could be explained in view of her intensive and dependent relationship with her husband, as well as her life prospects without her husband due to her severe motor disability. Her wish was not caused by an irrational fear of the future or depression. It was not based on loyalty to her husband, nor was she influenced by him. According to the psychiatrist the patient concluded independently that she did not want to go on living and that her wishes were consistent. The psychiatrist concluded that the patient had no psychiatric symptoms and that she was decisionally competent in relation to her request. The physician concluded that the request was voluntary and well-considered. He established that the patient was not depressed and that she had not been influenced by her husband. The physician felt this was supported by the psychiatrist’s findings. The independent physician concluded in his report, partly on the basis of his interview with the patient, that the due care criteria had been met.

At the committee’s request, the physician gave an oral explanation, in which he stated that the euthanasia process had been very rapid. While the physician was on holiday, the patient’s husband’s condition had deteriorated very fast. He had been admitted to hospital, probably with sepsis. When his condition had improved slightly, his attending physicians told him his lower leg had to be amputated, otherwise he could develop sepsis again very quickly, within one or two weeks. The patient’s husband refused to have his lower leg amputated, however. When the physician returned from his holiday, the husband had a ‘volcano’ in his foot.

The patient’s husband was used to being in charge. Over the years, the patient had said on several occasions that she did not want to be left behind on her own and asked the physician to help her if this was imminent. The physician had told her he would probably be unable to do anything for her. He hoped that she would die before her husband. When the physician returned from holiday the patient said she could not bear the new situation. She had seen with her own parents what happened to the surviving partner when the other one died. The physician concluded that the patient had her own substantial medical problems. When her husband died she would no longer have anyone to help her. She was already practically fully dependent on care due to her physical complaints. This dependence was a nightmare scenario for the patient. With regard to the symbiotic relationship between the patient and her husband, the physician said that it was not the case that one partner dominated the other. The patient’s husband had not influenced her.

When asked about the matter, the physician explained that there had been no time to find different independent physicians for the patient and her husband. He had not considered doing so either. The physician was of the opinion that it would only be necessary to consult two separate independent physicians in exceptional cases. He thought it was up to the independent physician, in such cases, to identify that necessity. The physician believed it would have been possible for the independent physician to assess both the patient’s case and her husband’s and then make a negative recommendation concerning one of them. He would have been able to do that himself. When the physician was driving to meet the couple he’d thought, ‘This is the right thing to do’.

At the committee’s request, the independent physician gave an oral explanation, which included the following. When asked about the matter, the independent physician said the symbiotic relationship between the patient and her husband formed the basis of the patient’s suffering. He met the patient and her husband at the hospital where the husband had been admitted. He did not speak to them separately because the room in the hospital was not suitable for that. The husband did the talking. The patient gave the impression she was fully dependent on him. All their lives the ouple had been focused on each other. They had both signed an advance directive years ago. Their requests for assisted suicide were linked. The independent physician remarked that during their meeting the patient was focused on her husband, but did answer the independent physician without involving her husband. It was easy to get her attention. The independent physician had not considered involving a second independent physician.

The independent physician described the patient’s dependence. The patient was certainly physically dependent on care as a result of the residual symptoms of the CVA. The independent physician confirmed that the patient’s wish to die was voluntary and not influenced by external factors. Her wish to die was very clear. The  independent physician was satisfied that she was able to make that choice herself. The underlying reason was her husband’s illness. He did not decide for her that she had to die too. Within the framework of his illness, she had made her own choice. When asked about the matter, the independent physician explained that in the event of a new, comparable case he would reach the same conclusion. He would, however, want to speak to the two partners separately, but in this case the circumstances had not allowed it.

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 patient had discussed her wish for euthanasia in the event of her husband’s death with the physician on several occasions and had been very consistent about it. Partly in view of the findings of the abovementioned psychiatrist, the committee was also satisfied that the patient had come to her own conclusions and had not been influenced by her husband.

The committee also considered with regard to the patient’s suffering that it was sufficiently clear from her medical record and the oral explanations given by the physician and the independent physician that she was suffering from serious medical problems and physical disabilities. As a result she was dependent to a great extent on other people for care. Her husband had always provided that care. The committee found that the physician could conclude that in view of her past life, her close relationship with her husband and the lack of a social network of her own, the prospect for this patient of a life in which she would be highly dependent on other people for her physical care, probably in a nursing home, meant
unbearable suffering without prospect of improvement. In the opinion of the committee, her suffering had a predominantly medical dimension. The physician had informed the patient sufficiently about her situation and her prognosis. Together, the physician and the patient could be satisfied that there was no reasonable alternative in the patient’s situation. With regard to the requirement that the physician must have consulted at least one other, independent physician, the committee considered as follows. In the event of simultaneous euthanasia requests by a couple, the committee deems it important for the physician to consider carefully whether it is preferable to consult one independent physician for both partners or a separate independent physician for each.

If, after deliberation, the conclusion is that one independent physician will be asked to assess

both requests, that physician will have to be extra alert to the question of whether he is able to form an independent judgment in both cases. After all, such situations can be tricky. The independent physician can find himself in a difficult situation if he finds that the due care criteria have been met in one case, but not in the other. In principle, the independent physician will have to speak with each partner separately to establish whether all the due care criteria have been met.

The committee noted that the physician consulted one independent physician with regard to both requests for euthanasia. This independent physician visited the patient and her husband at the same time. There was one interview between the independent physician and the couple, and on the basis of that interview the independent physician concluded in two separate reports that the due care criteria had been met. The independent physician did not speak to the patient and her husband separately. The committee concluded from his further, oral explanation that the independent physician deemed himself capable of making an independent judgment in both cases. In view of the above considerations and in particular of the patient’s dependence on her husband and the possibility that he might have influenced her wish for euthanasia, the committee believes it would have been better if the independent physician had spoken with each partner separately. Taking into account the findings of the aforementioned psychiatrist, who did speak with the patient without the husband present and who discussed the possibility of her being influenced by her husband in his report, the committee nonetheless in this case saw no reason to doubt the accuracy of the independent physician’s conclusions. The committee found that the physician had fulfilled the requirement of consulting at least one other, independent physician.