Substantive due care criteria cases
| Case ID | Due care criteria not met | Patient characteristics | Judgement summary |
| 2012-8 |
| A woman, 50–60 years old, in the terminal stages of Huntington’s disease | Patient had 7-year-old advance directive for EAS without trigger for implementation. Physician mentioned EAS 3 years prior, but patient became troubled, said she ‘didn’t want to “get the needle” ’. One year prior, he brought up EAS again and patient ‘did not become troubled’. Physician ‘considered this an indirect form of consent’ and later took ‘patient’s tranquil behavior’ to mean she ‘understood what she was being told’ despite the patient being incapacitated. RTE concluded, ‘the physician could actually not have interpreted the verbal and nonverbal behavior of the patient as a voluntary and well-considered request…’ and that the description of patient’s behaviour was not consistent with unbearable suffering. |
| 2012-17 |
| A woman, over 90 years old, had a stroke 4 years before death with a good neurological recovery. | Patient was lonely (‘alone in the world’) but healthy, felt her ‘life was complete’. Stopped eating and drinking but wanted EAS to die. Consultant claimed suffering ‘due to starvation’ as a medical basis; physician blamed the consultant, saying he would not have provided EAS without consultant approval. RTE concluded her ‘suffering cannot be primarily attributed to a medically classified disease or disorder, and therefore the physician could not have come to the conclusion that it was a matter of unbearable suffering in the sense of the law… [and] that there was no other reasonable solution’. |
| 2012-33 |
| A woman, 50–60 years old, stable for several years after a cerebrovascular accident due to cardiac arrest, with aphasia and hemiparesis. | Patient felt isolated due to aphasia but could communicate enough to convince doctors of desire and competence for EAS. Two consultants disagreed about suffering: ‘[a]ccording to the second consultant, the unbearable nature of her suffering was also apparent from the resolve of her request for euthanasia’. Physician did not keep records for last 3 months of her life and vacationed for 2 months after agreeing to provide EAS. Patient’s ‘problematic’ family also took vacation and delayed EAS. RTE stated, ‘In view of the long period that the patient withstood the suffering and the physician’s impression that if necessary she could have waited even longer, it would have been reasonable for the physician to have discussed the unbearable nature of the patient’s suffering more extensively with her…’ |
| 2013-91 |
| A man, 50–60 years old, diagnosed with an oesophageal carcinoma and metastatic colon cancer with little prospect of recovery. | The EAS physician refused to fill out key parts of his report, would speak only to physicians on the RTE and refused to answer questions even in interview, citing ‘physician confidentiality [sic]’. ‘The Committee, as a result of the lack of necessary information… was not put in a position to form a reasoned picture of whether the physician acted in accordance with the due diligence requirement from Article 2 sub a-d of the Act on Reviewing the Termination of Life on Request and Assisted Suicide’. |
| 2014-01 |
| A woman, 80–90 years old, suffered from depression for about 30 years. | A generalist End of Life Clinic physician saw patient only twice over 3 weeks, did not interview patient alone or consult any psychiatrists. Told the RTE he ‘had not a single doubt’ about patient meeting due care criteria, did not see the need to consult a psychiatrist and was unaware of the Dutch Psychiatric Association guidelines on EAS requests from psychiatric patients. The RTE determined ‘the physician did not act with the caution that would have been expected in the case of a requestsfor assisted suicide from a psychiatric patient. The physician in this case should have taken more time for interviews with the patient, also not in the presence of her children. Since the physician and the consultant lacked psychiatric expertise, the physician should also have contacted another expert’. |
| 2014-02 |
| A woman, 80–90 years old, placed in a nursing home after a second cerebrovascular accident that left her with cognitive disorders and aphasia. | Patient not competent, in a NH; had a 20-year-old advance directive, which she confirmed orally to her physician that requested EAS if she were permanently placed in NH. NH doctor noted patient to be a ‘quiet and friendly woman’, refused children’s request for EAS; children turned to End of Life Clinic. The Clinic doctor saw patient twice. Consultant saw in ‘[the patient’s] eyes… quite clearly her despair and unhappiness’ but also said it was a ‘very difficult case, and that the limits of the law would be sought here’. Physician ‘did not see any signs of unbearable suffering in the patient and based his decision exclusively on the fact that the patient was placed in a nursing home…’ RTE concluded that ‘The mere fact that the patient permanently had to leave her own environment and be admitted to a nursing home is insufficient to assume that the suffering is unbearable… the physician—merely on the basis of the picture of the patient that was outlined to him—expended insufficient time and effort in this situation to confirm the unbearable nature of the patient’s suffering’. |
| 2014-05 |
| A woman, 40–50 years old, with tinnitus for more than 10 years, severe hyperacusis and neuralgia; had history of psychiatric disorders including anorexia, post traumatic stress disorder, anxiety and depression. | Patient had history of not following physician advice and had halted EAS evaluation process several times. End of Life Clinic psychiatrist wrote a triage report 6 months prior and did not address psychiatric issues. SCEN consultant surprised End of Life Clinic physician by saying no further evaluation needed and told RTE that ‘she wanted to prevent the patient from having to go through another interview with an independent psychiatrist’. Consultant contacted triage doctor ‘twice to insist that she supplement the report with conclusions regarding DSM Axis I and Axis II based on the triage’. RTE was sceptical of this retroactive ‘supplement’. RTE determined the End of Life Clinic physician ‘lacked a clear somatic diagnosis and… the physician… should have had a psychiatric examination performed…especially since the physician initially had a ‘fishy’ feeling about this request… The physician conducted inadequate research on the existence of real options to ease the patient’s suffering…’ |
| 2015-01 |
| A woman, over 90 years old, with many non-terminal conditions including macular degeneration, intestinal problems, back pain and dysphasia. | Patient went to End of Life Clinic when her own doctor refused EAS. Patient refused examination by the clinic physician. The consultant did not think the request was well considered or the condition futile and recommended geriatric consult, but the patient refused. End of Life Clinic physician eventually convinced the consultant to change this decision. ‘The Committee is of the opinion [that the physician] too easily went along with the patient’s refusal to be examined by a geriatrician’. |
| 2016-21 |
| A man, 50–60 years old, with mild Parkinson’s disease and psychiatric issues related to coping. | Treating psychiatrist and neurologist thought a psychological component played a role in patient’s suffering. Family physician reluctant but consulted SCEN doctor who initially thought not hopeless but told family physician to refer patient to End of Life Clinic. Clinic physician saw patient twice within a week, consulted same SCEN doctor and without consulting new specialists deemed patient’s condition futile, contrary to what the previous specialists stated. Committee stated, ‘The physician was not obligated to further scrutinize the advice of the treating neurologist and the judgment of the psychiatrist other than to make accurate record of them. The physician, to reach a well-considered judgment of the hopelessness of the suffering and any treatment alternatives, must consult with the neurologist and the psychiatrist or another specialist expert in this field… The physician had to use this deliberation to check his own judgement against that of the above-named specialists’. |
| 2016-85 |
| A woman, 70–80 years old with Alzheimer’s disease. | Patient lacked capacity but had an advance directive. RTE noted: ‘From the wording of these clauses (“when I consider that the time is right for me” and “upon my request,”)…it can be deduced that the patient, when preparing [the advance directive], assumed that she herself could and would request euthanasia at the time she chose’. The physician covertly placed a sedative into the patient’s coffee (and gave it subcutaneously also) in order ‘to prevent the patient from resisting the administration of the euthanasic…’ However, ‘the patient made a withdrawing movement during the insertion of the infusion line, and sat up during the administration of the thiopental, after which she was held to prevent her from resisting further’. The physician justified her actions: ‘Since the patient was no longer mentally competent, [the patient’s] utterances were no longer relevant at that time.’ RTE further noted, ‘even if the patient had said prior to the implementation that she did not want to die, the physician stated without prompting that she would have proceeded with the termination of life. …the physician crossed a line with her actions’. Earlier in the report, the physician ‘emphasized that she wanted to be fully transparent regarding the manner in which the termination of life proceeded, since in the future, euthanasia might occur more frequently in incompetent patients’. |
SCEN consultants were trained by the Support and Consultation on Euthanasia in the Netherlands (SCEN) organisation (see box 1).
EAS, euthanasia and physician-assisted suicide; NH, nursing home; RTE, regional euthanasia review committees.