2014-36, general practitioner, multiple geriatric syndromes, unbearable suffering without prospect of improvement
KEY POINT: medical dimension to suffering
The patient, a man in his eighties, felt that life had nothing more to offer him. A registered general psychologist who was consulted concluded that he had a consistent wish for euthanasia. The patient’s suffering was caused by geriatric syndromes which caused increasing debilitation. Due to his functional decline and dependence on others, the patient no longer considered his life meaningful. Living in this way was more than he could bear. The physician and the independent physician established satisfactorily that the patient’s suffering had a medical dimension and that this was palpably unbearable. There were no reasonable alternatives available.
Due to his advanced age, the patient, a man in his eighties, was suffering from a combination of physical symptoms and the feeling that life had nothing more to offer him. The patient and his wife had been together for many years. The bond between them had been extremely close and they needed no one else. They had no children. The patient had cared for his wife for years when she was ill. That had given him a final purpose in life. Around six months before his death, his wife died and from then on he lost interest in the world. He had always been a loner. He had never had any real friends and he felt like an outsider.
The patient could no longer follow the radio or television. He also no longer internalised anything he read. The patient was tired and felt drained, and no longer wanted to do anything. His motor skills were deteriorating, partly as a result of arthrosis and osteoporosis. He was having difficulty walking and his hands had become clumsy, which meant he could no longer perform certain actions, such as making a sandwich. The patient was afraid he would end up in a wheelchair and become even more dependent. He also had urinary problems and always wore incontinence pads. The patient did not want any more psychosocial support or involvement with others. His condition was incurable. There were no more treatment options.
The patient’s suffering consisted of the feeling that continuing to live this way was completely devoid of meaning and quality. He was increasingly debilitated due to old age, and could no longer do very much. But his suffering was mainly made unbearable by the feeling that he had nothing more to expect from life. The patient regarded his life as completed. He experienced his suffering as unbearable.
The patient had discussed euthanasia with the physician before. More than two months before his death, the patient asked the physician to actually perform the procedure to terminate his life. The physician had known the patient for many years and understood the patient’s perspective. On the independent physician’s advice, the patient spoke several times with a registered general psychologist, who concluded that the patient’s wish was consistent.
At the request of the committee, the physician gave a further, oral explanation concerning the question of whether the unbearable nature of the patient’s suffering could to a sufficient degree be found to be caused by a recognised disease or medical condition.
In the last few years of his life, the patient could hardly do anything anymore. He was suffering from osteoporosis. He was in pain from vertebral compression fractures. He fell frequently, causing large haematomas. Following a CVA one year before his death, the left side of his body was partially paralysed. He suffered from frequent headaches. He had decreased kidney function, which made it difficult to treat the pain with medication. The patient suffered from urinary incontinence. He could only walk a few steps, partly due to arthrosis of the knee. He also suffered from atrial fibrillation. The patient’s eyesight was poor and he could no longer read. The patient’s mental health was good. His wife had been his reason for living. His loyalty and devotion to her had kept him going, despite all his physical problems. He had looked after her as long as he could, even though she no longer recognised him because she was suffering from Alzheimer’s disease. After her death, the patient regarded his life and suffering as meaningless.
The physician was convinced that this suffering was unbearable to him and that there was no prospect of improvement. The unbearable nature of his suffering, which was palpable to the physician, was caused by untreatable pain, incontinence, a high risk of falling, increasing disability, loss of autonomy and dependence on care. He had been suffering for some time, but after his wife’s death (they had no children) the patient could not and did not want to go on.
At the request of the committee, the independent physician gave a further, oral explanation. The independent physician thought the patient was a very nice man who was easy to talk to. However, the patient did not want close social contacts. This was partly due to his physical disabilities, such as deafness and impaired eyesight. His motor skills were deteriorating and he could hardly walk at all. He rarely went outside. Incontinence also contributed to his considerable disability. After the patient’s wife died, he requested euthanasia. When the independent physician first visited him, the patient said that he wanted to see his next birthday before dying. The independent physician then wanted to know how consistent the patient’s wish was. The patient subsequently spoke with a registered general psychologist several times. During his second visit to the patient, the independent physician became convinced that the patient really wanted euthanasia. He certainly found the patient to be decisionally competent. After his wife’s death, the patient wanted no more involvement with others in the form of care, therapy or family visits. He did not want to be dependent on other people.
The independent physician was satisfied that the patient’s suffering had a physical component, but believed that the patient’s personality certainly contributed to the way he experienced his suffering.
The committee considered whether the unbearable nature of the patient’s suffering was to a sufficient degree caused by a recognised disease or medical condition. After reading the patient’s medical record and speaking to the physician and the independent physician, the committee concluded that the patient’s suffering was caused by geriatric syndromes which caused increasing debilitation. These aging-related conditions, including arthrosis of the knee, pain from vertebral compression fractures caused by osteoporosis, headaches, poor kidney function, incontinence, impaired vision, atrial fibrillation and hemiparesis following a CVA, were closely related to the medical domain. After the patient’s wife died, he felt his life no longer had any meaning. He had felt his suffering was unbearable for some time, but he had kept on going to support his wife in her illness.
Due to his functional decline and increasing dependence on others, and in view of his past life and personal values, the patient could no longer give his life meaning. Living in this way was more than he could bear. The committee found that the physician and the independent physician had established satisfactorily that the patient’s suffering had a medical dimension and that it was palpably unbearable. There were no reasonable alternatives available.