2017-14, due care criteria complied with

Non-straightforward notification, disagreement among specialists consulted.

The patient, a woman in her eighties, was diagnosed three years before her death with a dementia syndrome that most closely resembled Alzheimer’s disease. Her condition was incurable. The patient had a dedicated care worker who provided advice and support, and she had moved into a care home. In the final period before her death, her dementia had reached such an advanced stage that admission to a secure, psychogeriatric ward was deemed necessary.

The patient was utterly opposed to this idea, and she repeatedly threatened to jump out of the window if she was moved. Her suffering consisted of increasing loss of memory and grasp of the world around her. She suffered severely from the prospect of being admitted to a secure ward and thus losing her independence. This prospect led to increased anxiety and irritability.

She associated being placed in a secure ward with traumatic experiences she had gone through in the war and she did not want to lose her freedom again. Having to go into such a ward was the absolute limit for her. If that were to happen, also given her experience of close family members with dementia, she would not want to go on living.

Around 20 years before her death, the patient had drawn up an advance directive for the first time. Two years before her death, she drew up a new advance directive concerning her mental condition as well as her physical deterioration. On the basis of his conversations with the patient, the physician established that she was very resolute in her refusal to go into a secure ward, and that she was also very resolute in her wish for euthanasia. He had been told by the head of care of the ward where she was staying that the patient had already said two years previously, during her intake interview, that she would never want to go into a secure ward. The patient had discussed this regularly with her since then.

About a month before the patient’s death, at the physician’s request, an independent elderly-care specialist examined the patient to assess her decisional competence. According to the elderly-care specialist, the patient appeared to have no insight into her disease, prognosis and disabilities. She seemed to have no oversight of the situation or insight into the relevant issues. He considered her to be decisionally incompetent in terms of overseeing complex issues and taking decisions on such issues.

The physician consulted an independent physician who was also a SCEN physician and a geriatric psychiatrist. According to the independent physician, the patient did not have a psychotic disorder or a mood disorder, and had a powerful need for control and independence, partly due to her traumatic war experiences. She was no longer able to understand the complexity of her situation. However, if the subject was put to her in a calm manner, she was able to indicate clearly that she wanted to retain her freedom, that she did not want to be placed in a secure ward, and that she did not want to suffer any further debilitation.

At this point, she understood the situation sufficiently and was consistent in her wishes, according to the independent physician. The latter concluded that the patient was decisionally competent regarding her request for euthanasia, and her request was voluntary and well considered.

The committee considers that a request for termination of life from a patient suffering from progressive dementia must be responded to with even greater caution than usual. There may be doubts about whether the patient is decisionally competent, and in view of the nature of the condition, whether the request is voluntary and well considered. It may also be unclear whether the patient’s suffering is in fact unbearable. In the committee’s opinion, the physician exercised sufficient caution in this case.

The physician consulted an independent elderly-care specialist, as well as an independent physician who was also a geriatric psychiatrist. Both gave their opinion on the patient’s decisional competence. The elderly-care specialist considered her incompetent with regard to making decisions on complex issues. The independent physician, on the other hand, was of the opinion that she was decisionally competent regarding her request for euthanasia.

In view of the independent physician’s extensive substantiation of his opinion, compared to the more cursory substantiation given by the elderly-care specialist, and in view of the conversations the physician had with the patient, the committee found that the physician could consider the opinion of the independent physician/geriatric psychiatrist to be more convincing and that he could reasonably conclude that the patient was decisionally competent regarding her request.

The committee found that the physician could be satisfied that the patient’s request was voluntary and well considered and that she was suffering unbearably with no prospect of improvement. The other due care criteria were also fulfilled.