Euthanasia in the Netherlands

The physician must be satisfied that the patient’s request is voluntary and well-considered.

Patients must make request themselves

A request for euthanasia or assisted suicide must be made by the patient concerned. Though family members and often professional care staff are involved in the patient’s request, the law does not require their approval or consent. The patient’s wishes are paramount.

Decisional competence

The patient must be decisionally competent. This means that the patient is able to understand relevant information about their situation and prognosis, consider any alternatives, and assess the implications of their decision. It is not possible for a patient’s parents or legal representatives to make a request on the patient’s behalf.

Voluntary request

The patient’s request must be voluntary. This means that:

• the patient is capable of determining their own wishes (internal voluntariness). A request is not voluntary if, for example, it arises from a psychiatric or somatic disorder that affects the patient’s mental capacity;
• the patient must have made their wishes known without pressure or undue influence from others (external voluntariness).

Well-considered request

The patient’s request must be well-considered. This means that the patient has given the matter careful consideration on the basis of adequate information and a clear understanding of their illness.

Advance directive: not a statutory requirement

The Act does not require patients to put their request in writing, but an advance directive may provide extra clarity.

An oral request to the physician is sufficient unless the patient is no longer capable of expressing their wishes. An advance directive can replace an oral request in cases where at the moment when termination of life is being considered the patient is no longer capable of expressing their wishes. The patient must however have been decisionally competent when drawing up the directive. The physician must also check whether the other due care criteria have been met.

Request from a minor

Minors over the age of twelve may ask their physician to perform euthanasia. The Act distinguishes between two age categories:

• minors aged between 12 and 16: euthanasia may only be performed with the consent of the child’s parent(s) or guardian;

• minors aged 16 or 17: these patients may make an independent request but their parent(s) or guardian must be consulted in the decision-making process.

Terminating the lives of children under the age of twelve is regarded as termination without a request. It falls outside the scope of the Act.

The physician must be satisfied that the patient’s suffering is unbearable and without prospect of improvement.

Without prospect of improvement

The patient’s suffering is considered to be without prospect of improvement if the disease or disorder causing the suffering is incurable and there are no means of alleviating the symptoms so that the suffering is no longer unbearable. Medically speaking, the absence of any prospects for improvement can be determined with a reasonable degree of objectivity. The physician establishes this on the basis of the diagnosis and prognosis. Whether curative or palliative treatments are a realistic option depends on two things: the improvement that can be achieved and the burden such treatment would place on the patient.

Unbearable suffering

The unbearable nature of suffering is more difficult to establish because it is a subjective notion. What is bearable for one patient may be unbearable for another. Whether suffering is unbearable depends on the patient’s current situation and their future prospects, physical and mental stamina, and personality.

The unbearable nature of the patient’s suffering must be palpable to the physician. The physician must therefore not only be able to empathise with the patient’s situation, but also see it from the patient’s point of view. The physician must demonstrate convincingly to the review committee assessing the case that the suffering of this particular patient was palpable to the physician.

The physician must have informed the patient about the patient’s situation and prognosis.

The review committees assess whether the physician or other attending physicians informed the patient about the patient’s condition and prognosis, and examine how this was done. A patient cannot make a well-considered decision without a full understanding of the disease, diagnoses, prognoses and treatment options. It is the physician’s responsibility to ensure that the patient is fully informed.

The physician must have come to the conclusion, together with the patient, that there is no reasonable alternative in the patient’s situation.

A shared decision-making process

The patient and the physician together come to a decision regarding euthanasia. It must be clear to both of them that termination of life on request or assisted suicide is the only reasonable way of relieving the patient’s suffering.

Patient may refuse treatment

The provision of good medical care, especially palliative care, is a key factor in end-of-life decisions. This does not mean that patients have to undergo every possible form of care or treatment. Patients are entitled to refuse care or treatment, including palliative options, for instance because the side-effects outweigh the positive effects for them. Or it may be that the patient cannot or does not wish to tolerate the (fear of) continuing loss of dignity, dependence or the absence of any prospects of improvement. Here too there may be no reasonable alternative.

Reasons for refusal

If treatment was refused, the review committee assesses whether there was a ‘reasonable alternative’ in the case in question. The physician’s report should explain the reasons why the patient found possible alternatives to be unreasonable or unacceptable.

The physician must consult at least one other, independent physician, who must see the patient and give a written opinion on whether the statutory due care criteria have been fulfilled.

Ensuring a careful decision-making process

The purpose of consulting at least one other, independent physician is to ensure that the physician’s decision is reached as carefully as possible. It helps the physician establish whether the due care criteria have been met. The physician must take the independent physician’s opinion very seriously. If the independent physician’s advice is not followed, the physician will have to provide convincing arguments to justify this.

Independent physician

The independent physician must be independent of the attending physician and the patient. According to the Royal Dutch Medical Association (KNMG), this means that a member of the same medical practice or partnership, a registrar, or a physician who in some other way is in a relationship of dependence with the physician asking for the independent assessment cannot in principle be deemed to be independent. It is also important to avoid anything that might suggest that the physician is not independent. There must be no family or business relationship between the two physicians or, in principle, any broader cooperative relationship.

The independence of the independent physician in relation to the patient means there can be no family relationship or friendship between them, nor can the independent physician be treating the patient. To safeguard this independence, it is customary and advisable to contact a SCEN physician for an independent assessment through the SCEN organisation (Euthanasia in the Netherlands Support and Assessment Programme).

The independent physician must see the patient

To obtain a clear insight into the patient’s condition, the course of the disease and the patient’s situation, the independent physician must see the patient personally. The main rule is that the independent physician must be able to communicate with the patient, preferably in private. Nevertheless, it is possible to conceive of certain exceptional circumstances in which a personal conversation between the patient and the independent physician is not feasible: for example, a sudden and unexpected deterioration in the patient’s situation. The independent physician can ‘compensate’ for this by consulting other sources of information – the medical records and the advance directive – or by talking to other relevant persons.

Independent physician’s report

After visiting the patient, the independent physician must draw up a report. The report must say whether the independent physician believes that the physician has complied with the due care criteria and give reasons supporting this view. It is desirable for the independent physician to explicitly describe their relationship with the physician and the patient. The independent physician is responsible for the contents of this report, but the physician must ascertain whether it is of sufficient quality and whether the independent physician has given their opinion on whether the due care criteria have been fulfilled.

The independent physician’s opinion and written report are of great importance to the physician in reaching a decision. They also help the review committee obtain an insight into the case.

Limited validity of independent physician’s report

In certain circumstances considerable time may elapse between the independent physician’s visit and actual compliance with the patient’s request. This may mean that the physician has to consult the independent physician for a second time. It may be that a telephone call will suffice or the independent physician may have to visit the patient again, depending on the amount of time that has elapsed and whether the patient’s situation has changed.

The physician must have exercised due medical care and attention in terminating the patient’s life or assisting in their suicide.

Proper administration of the correct substances: only by a physician

The requirement of due medical care has two aspects. First, the physician must administer the correct substances following the proper medical procedure. Second, it is the physician who must terminate the patient’s life. The physician is not permitted to let others, such as nursing staff, perform the procedure.

Performing euthanasia/assisting in suicide

In cases of euthanasia, or termination of life on request, the physician actively terminates the patient’s life by administering euthanatics, usually intravenously. In the case of assisted suicide, the physician gives a euthanatic to the patient, who then ingests it independently. The physician must remain present or in the immediate vicinity until the patient dies, as complications may occur. For example, the patient may vomit the potion back up or it may take a considerable time for death to ensue. In such cases, the physician may have to terminate the patient’s life after all. The physician must discuss this possibility beforehand with the patient and the patient’s family. The physician may not leave the euthanatic with the patient as this presents risks to the patient and to others.

KNMG/KNMP Guidelines for the Practice of Euthanasia and Physician-Assisted Suicide

In assessing whether a physician has exercised due medical care in terminating a patient’s life on request or assisting in suicide, the review committees refer in principle to the KNMG/KNMP Guidelines for the Practice of Euthanasia and Physician-Assisted Suicide of August 2012. The Guidelines advise physicians and pharmacists on practical and effective methods of performing euthanasia and assisting suicide. They list recommended substances, dosages, methods of administration and materials. The Guidelines replace Standards for Euthanasia published by the KNMG in 2007.

Request for additional information from the review committee

A review committee may ask the physician for additional information if, in the documents received:

• the physician has not stated the dosages of the substances administered, or has not stated it in milligrams;
• the physician has not administered the dosages recommended in the Guidelines;
• the physician has not stated how the substances were administered.

In cases of termination of life on request the physician must be sure that the patient is in a deep coma before administering the muscle relaxant. It is extremely important to use the coma-inducing substance recommended by the Guidelines in the correct dosage to ensure that the patient does not perceive the effects of the muscle relaxant. It is vital for the physician to establish the depth of coma before administering the muscle relaxant, for example by checking the corneal or eyelash reflex or by applying pain stimuli.