2016-11, other physician, combination of somatic and psychiatric disorder, independent assessment

KEY POINT: difference in views between the physician and the independent physician as to whether the request was well-considered and with regard to the patient’s suffering; the physician consulted another independent physician

The patient, a man in his seventies, had been suffering from frequent migraines for more than 50 years. Treatment with medication, prescribed by a neurologist, had no effect. The patient therefore stopped taking the medication, but from then on reported suffering a great deal from anxiety.

Thirty years before his death he had been declared completely unfit to work. In the 10 to 14 years before his death he developed other physical symptoms, including high blood pressure, abdominal pain, pain in his joints, dizziness and balance problems. These symptoms became more severe over the years.

In the 25 years before his death the patient received treatment from several psychiatrists in the form of talk therapy and medication for depression.

Four years before his death he was briefly treated in a clinic, and two and a half years before his death he spent a year in a clinic after multiple suicide attempts. In that year he was treated with medication for depression and received ECT (electroconvulsive therapy) five times.
Because he experienced no perceivable improvement he refused any further ECT.

Two years before his death the previous diagnosis (depression) was changed to one of dysthymic disorder (a less severe form of depression), PD-NOS (personality disorder – not otherwise specified) and a pain disorder connected to psychological and physical factors.

His condition was incurable. He could only be treated palliatively (care aimed at improving quality of life). The patient no longer wanted to use medication for his psychological symptoms due to the unpleasant sideeffects.
Because of his many physical problems he no longer left the house and as a result of his personality disorder he no longer had a socialnetwork. He could no longer watch television or pursue a hobby. All he did was lie in bed aimlessly, waiting for death. He felt that living this way was futile and degrading and he experienced his suffering as unbearable.

He asked the physician to help him with euthanasia. The physician asked an independent psychiatrist to assess whether the patient was decisionally competent and whether there were any realistic treatment options that could alleviate his suffering.

In the opinion of the psychiatrist, the patient was decisionally competent in relation to his request for euthanasia and there were no treatment options left with regard to the psychiatric component of his suffering.

The physician consulted an independent SCEN physician. The independent physician considered the patient to be decisionally competent, but doubted, in view of his personality, whether the wish could be said to be well-considered. The independent physician was also not convinced that the patient’s suffering was unbearable and without prospect of improvement.

The physician then asked another SCEN physician to visit his patient. This SCEN physician not only contacted the physician asked to perform euthanasia and the psychiatrist he consulted, but the first independent physician as well. He also consulted several fellow SCEN physicians. This enabled him to make a more specific assessment of whether there were any reasonable alternatives that could alleviate the man’s suffering. The second independent physician concluded that the due care criteria had been complied with.

The committee observed that when dealing with a request for euthanasia, the physician is not meant to ‘shop around’ for an independent physician, i.e. keep searching until he has found an independent physician whose opinion is agreeable to him.
When an independent physician is of the opinion that the due care criteria have not yet been fulfilled or raises points of criticism, it is up to the physician to explain as clearly as possible why he nonetheless is satisfied that the due care criteria have been fulfilled.

The committee also found that the physician made an effort to substantiate his own views and was prepared to enter into discussion about them. The committee found that the physician had acted in accordance with the due care criteria.