2017-79, due care criteria not complied with

Non-straightforward notification, suffering without prospect of improvement, absence of reasonable alternatives.

The patient, a woman in her eighties, was suffering from osteoarthritis, which caused pain in her joints, limbs and back, and impaired movement. These impairments included stiffness, difficulty in walking and repeated falls.

As a result, she became less and less self-reliant. In addition she was suspected to have vascular problems, and suffered from oedema and increasing shortness of breath (probably caused by heart failure or a lung disorder combined with long-term high blood pressure).

The symptoms had emerged over the years and increased gradually. In the final 18 months before her death the patient experienced increasing disability due to her conditions. She no longer went outside and had fallen several times in the house. After shuffling around briefly, she had to stop and catch her breath.

Due to her poor condition, the patient could no longer keep dogs. Dogs meant the world to her, so she experienced her quality of life as being even worse. All the patient could do was read, and sometimes watch television, and in the afternoons she often went to bed.

The patient refused to be examined or treated by specialists. She no longer saw any point in that, on account of her age and life expectancy. She also did not want to be ‘messed around with’ any more. As her body was becoming increasingly worn out, she refused any aids that would help her mobility. Diuretics could have helped manage her heart failure to an extent, but her mobility would have remained impaired.

Her suffering consisted of her becoming increasingly dependent on other people, to which she was totally opposed. In addition she was often nauseous, she slept badly, and her pain could not always be alleviated adequately. She was an exceptional and very self-willed woman, who had little time for interference from other people.

She suffered from the fear of further deterioration, which would ultimately result in her becoming entirely dependent on others. She experienced her suffering as unbearable. The physician was satisfied that this suffering was unbearable to her and without prospect of improvement according to prevailing medical opinion. According to the physician, there were no  alternative ways to alleviate her suffering that were acceptable to the patient.

The patient had discussed euthanasia with her general practitioner several months earlier. The general practitioner, however, was of the opinion that this was a ‘completed life issue’ and that he should therefore not grant her request for euthanasia. The patient had attempted suicide. She then contacted the SLK.

The SLK physician first visited the patient over a month before her death. On that occasion, the patient asked the physician to actually perform the procedure to terminate her life. She repeated her request during the physician’s next two visits.

The physician concluded that the request was voluntary and well considered. The physician was convinced that if the patient no longer had any disabilities, she would not have requested euthanasia.

The committee wanted to know how the physician, partly in light of the relatively short time the process took, had come to the conclusion that the patient was suffering unbearably without prospect of improvement.

The physician explained that after speaking with the patient three times and studying the background information, she had gained sufficient insight into the unbearable nature of the patient’s suffering. Her situation and the way she was living was at odds with her independent character.

Mainly on the basis of the patient’s impaired mobility and the impact this had on her life, the physician concluded that the patient was suffering unbearably without prospect of improvement.

The physician indicated she had looked at possible treatment options and had tried to discuss them with the patient. The patient indicated several times that she was completely opposed to being examined or treated. The SLK nurse added that any kind of aid was a bridge too far for the patient. She even refused to discuss using a rollator. The physician was of the opinion that there were no other treatment options available for the patient.

When asked about this, the physician indicated that the patient’s pain and shortness of breath could possibly have been alleviated by prescribing additional medication. However, as the patient turned down any suggestion of further examination and treatment, the physician did not raise these issues again. The decisive factor for the physician was that there nothing more to be gained in relation to improving the patient’s mobility.

In the physician’s view, the patient had such difficulty walking that she could not have regained her mobility. The physician pointed out that the independent physician also concluded that there were few treatment options  available.

The physician contacted the patient’s general practitioner by phone, because she wanted to know why the general practitioner could not or would not help the patient. Unlike the physician, the general practitioner considered that this was a ‘completed life issue’.

The physician was aware  that no further examination had taken place, and agreed that it is difficult when patients refuse to be examined or treated. However, the physician did not want to abandon the patient. As regards the due care criteria that the physician must be satisfied that the patient is suffering without prospect of improvement and that there must be no reasonable alternative, the committee found as follows.

There is no prospect of improvement if the disease or disorder that is causing the patient’s suffering is incurable and the symptoms cannot be alleviated to the extent that the suffering is no longer unbearable. This must be determined in the light of whether there are realistic options, other than euthanasia, that would end or alleviate the symptoms.

In considering whether there is any realistic prospect of alleviating the symptoms, account must be taken both of the improvement that can be achieved by palliative care or other treatment and of the burden such care or treatment would place on the patient.

It is thus clear that the assessment of the prospect of improvement is closely linked to determining whether there is a reasonable alternative. If there are less drastic ways of ending or considerably reducing the patient’s unbearable suffering, these must be given preference. The physician and the patient must together arrive at the conclusion that no reasonable alternatives are available to the patient.

The perception and wishes of the patient are important. There is an alternative to euthanasia if there is a realistic way of alleviating or ending the suffering which may – from the patient’s point of view – be considered reasonable (see the Euthanasia Code 2018, p. 25).

The committee established that the patient was suffering from a range of symptoms. The physician indicated that she tried to discuss available treatment options with the patient, but that she refused any kind of treatment. However, in the committee’s opinion it would have been appropriate for the physician – before carrying out the patient’s request – to have set the condition that the patient first try some treatment options that were not invasive or burdensome.

If a patient refuses any kind of examination and possible treatment of their symptoms, it is impossible to properly assess whether there is any prospect of improvement. It is essential to continue to carefully consider alternatives to euthanasia. In the present case, those possible alternatives were explored insufficiently.

For instance, the patient’s pain and shortness of breath could possibly have been alleviated by prescribing medication, which might also have improved her mobility. If, after some time, it became clear that there was no improvement, or insufficient improvement, in the patient’s situation despite the treatment, the physician could then have proceeded with euthanasia.

The committee considered that although there is no statutory requirement for the physician and the patient to be in a treatment relationship, a physician who is not the patient’s attending physician will generally have to argue plausibly that sufficient time was taken to appraise the patient’s situation in relation to the statutory due care criteria (see the Euthanasia Code 2018 p. 16).

In the present case, however, the physician concluded in a very short space of time that there was no reasonable alternative. The physician did not investigate sufficiently whether there were reasonable alternatives other than euthanasia that would alleviate the patient’s symptoms, which might reduce the unbearable nature of her suffering.

The committee is therefore of the opinion that the physician could not be satisfied that there were no other ways to alleviate the suffering and that therefore there was no prospect of improvement. The physician did not act in accordance with the statutory due care criteria laid down in section 2 (1) (b) and (d) of the Act.