2016-52, general practitioner, combination of disorders, independent assessment

KEY POINT: physician proceeded with euthanasia despite the fact that the independent physician thought the due care criteria (reasonable alternatives) had not been complied with. Physician has clearly explained why he disregarded the independent physician’s assessment.

The patient, a woman in her eighties, suffered from a combination of conditions: she had polyarticular osteoarthritis (wear and tear in several joints) in her back, hands, shoulders, knees and feet, suffered from neuropathy (a nerve disorder) and was hard of hearing. In addition she had suffered all her life from depression and obsessive-compulsive disorder (uncontrollable thoughts/actions and a fear that something serious will happen if those actions are not performed).

She had received treatment including medication and electroconvulsive therapy (in which an electric current is passed across the brain). Her condition was incurable. She could only be treated palliatively (care aimed at improving quality of life). The patient’s suffering consisted of pain, fatigue, dizziness, hearing loss, loss of mobility, increasing dependence on others for care, mood-related problems and obsessive thoughts.
Sometimes her legs would buckle and she used a rollator when walking. She was afraid of falling, which was understandable because of the deformity in her feet.

In the final weeks before her death she hardly went outside and her social circle had become very small. She was unable to take part in a group conversation. She was at the end of her tether.

The physician was satisfied that this suffering was unbearable to her and with no prospect of improvement according to prevailing medical opinion.

The independent physician consulted by the physician found that due to her pain, fear of falling and increasing dependence the patient’s suffering was palpably unbearable. In his opinion, however, not all treatment options had been tried, such as better pain medication or physiotherapy aimed at fall prevention. The independent physician therefore concluded that the due care criteria had not been fulfilled.
The physician performed the euthanasia procedure nonetheless.

The committee then invited the physician to provide further information in person. It asked him why he had not followed the independent physician’s suggestions and why he been satisfied that there were no more reasonable treatment options, leading to the conclusion that the patient’s suffering was without prospect of improvement.

The physician replied that adjusting the pain medication would not have made any difference to the patient’s suffering from her perspective. Attempts had already been made in that area which had not produced sufficient results and had many side-effects. The only option would have been to give her morphine for the pain, but that would have increased the risk of falling and her constipation, which she had already found to be very troublesome.
In the physician’s view, she was beyond the stage of taking a fall prevention course. This was not a reasonable alternative, all the more because she had been treated by a physiotherapist for months.
Moving her to a nursing home could have helped solve the care problem, but would not have alleviated her suffering. On the contrary, losing her familiar surroundings would have added an extra dimension to her suffering.

The committee found that physicians may disregard a negative recommendation by the independent physician and proceed with euthanasia. According to the Act the physician is responsible, but he will have to explain clearly why he disregarded the independent physician’s assessment.

In this case the committee is of the opinion that the physician, in his reports and during the interview with the committee, explained in great detail and very convincingly why he thought the patient’s suffering was without prospect of improvement and why there were no reasonable alternatives to alleviate the suffering.

The committee found that the physician could be satisfied that this was the case. The other due care criteria were also fulfilled.