1998


Physician-assisted suicide in psychiatry: developments in The Netherlands.
Schoevers-RA; Asmus-FP; Van-Tilburg-W
Psychiatr-Serv. 1998 Nov; 49(11): 1475-80

Physician-assisted suicide can now be officially and legally carried out for psychiatric patients in The Netherlands who request it, provided that criteria are met. The authors describe two recent cases of psychiatric patients whose suicides were assisted by their psychiatrist. They critically examine the guidelines for physician-assisted suicide in psychiatry. The criteria address the decision of the patient to be assisted with suicide, which must be voluntary and well considered, and the patient's desire to die, which must endure over time. The patient's suffering must be unacceptable, and the disorder incurable. The authors conclude that important aspects of psychiatric practice are not addressed in the guidelines, which were originally developed for use in somatic medicine. The assessment of treatment prognosis in psychiatry is not accurate enough to allow a final decision about incurability. Boundaries of the psychiatric therapeutic relationship are violated in physician-assisted suicide. The therapist's inability to objectively assess the patient's wish to die is overlooked. Because the general public will continue to ask for clarity on the issue of euthanasia and physician-assisted suicide, the authors believe that an open discussion of both ethical and professional issues is the best option.


Beliefs concerning death, dying, and hastening death among older, functionally impaired Dutch adults: a one-year longitudinal study.
Sullivan-M; Ormel-J; Kempen-GI; Tymstra-T
J-Am-Geriatr-Soc. 1998 Oct; 46(10): 1251-7

OBJECTIVES: Population surveys have documented increasing public support for euthanasia and assisted suicide but have not focused on the population of chronically ill older persons, obtained detailed sociocultural or health status information, or performed repeat assessments. This study seeks to describe the views of functionally-impaired Dutch elders on death, dying, and hastened death and to relate these to sociocultural and health status. DESIGN: One-year prospective epidemiologic survey. SETTING AND PARTICIPANTS: Community-dwelling participants in the longitudinal component of the Groningen Longitudinal Aging Study were assessed at home by interview and questionnaire in 1994 (n = 632) and again in 1995 (n = 575). MEASUREMENTS: Independent variables were sociocultural characteristics (eg, age, sex, income, education, religious affiliation, strength of religious belief), physical health status (number of chronic medical conditions, functional impairments), and mental health status (life satisfaction, self-efficacy, anxiety, depression, and neuroticism). Dependent variables were preoccupation with and fear of death, fears of the dying process, and attitudes toward hastened death. RESULTS: Low and stable rates of preoccupation with death and fear of death were found. Occasional but not persistent fears about the dying process were common. Fears of death and dying were most closely related to health status, especially mental health status. Views concerning hastening death were most strongly related to sociocultural variables, especially religious belief and affiliation. There was little change over the 1-year follow-up, with a trend toward less fears of death and dying and less support for hastened death. Significant changes in fears of death and dying and attitudes toward hastened death were not seen even in the 25% of subjects with the greatest deterioration in activities of daily living or greatest increase in anxiety and depression during the 1-year follow-up. CONCLUSION: Beliefs about death, dying, and hatened death are stable over 1-year follow-up. Fears of death and dying are most strongly related to mental health in this community sample. Attitudes about hastening death are primarily related to religious belief and secondarily to mental health. Mental health factors may determine the distress associated with the prospect of death and dying, whereas religion may dictate the actions considered proper when dying.



An ethical perspective on euthanasia and assisted suicide in The Netherlands from a nursing point of view.
van-der-Arend-AJ
Nurs-Ethics. 1998 Jul; 5(4): 307-18

In the Netherlands, euthanasia and assisted suicide are formally forbidden by criminal law, but, under certain strictly formulated conditions, physicians are excused for administering these to patients on the basis of necessity. These conditions are bound up with a long process of criteria development. Therefore, physicians still live in uncertainty. Future court decisions may change the criteria. Apart from that, physicians can always be prosecuted. The position of nurses, however, is perfectly clear; they are never allowed to administer euthanasia or assisted suicide. Nevertheless, they should be involved in the decision-making process because they are an important source of information and have consultation skills. The openness of the discussion about these issues in the Netherlands may prevent an escalation of medical or nursing responsibility and falling victim to the 'slippery slope'.


Dutch court decisions on nonvoluntary euthanasia critically reviewed.
Jochemsen-H
Issues-Law-Med. 1998 Spring; 13(4): 447-58

The author critically reviews Dutch court decisions on nonvoluntary euthanasia. First, he examines euthanasia practice in the Netherlands. The author next discusses in detail the 1995 cases of two physicians who were prosecuted for terminating the lives of infants who were severely ill and disabled. The courts accepted nonvoluntary euthanasia and relied on the physicians' defense of necessity. Jochemsen exposes serious flaws in the reasoning of the courts and concludes that newborns with congenital disorders should be given appropriate palliative care. Jochemsen fears that by extending the practice of euthanasia to infants with disabilities the Dutch courts have taken another step toward endangering the lives of all incompetent persons.


Cases of euthanasia and physician assisted suicide among AIDS patients reported to the Public Prosecutor in North Holland.
Onwuteaka-Philipsen-BD; van-der-Wal-G
Public-Health. 1998 Jan; 112(1): 53-6

BACKGROUND: Euthanasia is performed relatively frequently among AIDS patients. OBJECTIVE: To examine the relationship between euthanasia and physician assisted suicide (EAS) and AIDS. METHODS: A descriptive retrospective study in which data was collected from all cases of EAS which were reported to the Public Prosecutor in North Holland between 1984 and 1993. RESULTS: In 7% of the reported cases of EAS the patient had AIDS, and in most of these cases the physician involved was a general practitioner. Both the percentage of AIDS among the cases of EAS and the percentage of EAS among all deaths due to AIDS increased over the years. In 1992, 23% of all deaths due AIDS were reported as cases of EAS. CONCLUSIONS: It seems, in recent years, that EAS has been performed on at least one out of three AIDS patients, which is a far greater percentage than found among other patients.


Physician-assisted suicide and euthanasia in The Netherlands: a report to the House Judiciary Subcommittee on the Constitution.
Issues-Law-Med. 1998 Winter; 14(3): 301-24

1997

Dutch euthanasia revisited.
Fenigsen-R
Issues-Law-Med. 1997 Winter; 13(3): 301-11

The results of a follow-up study of euthanasia by the Dutch government, five years after the first study, were published on November 26, 1996. This article provides a detailed review of the two reports comparing and contrasting the statistics cited therein. The author notes that the "rules of careful conduct" proposed by the courts and by the Royal Dutch Society of Medicine were frequently disregarded. Special topics included for the first time in the second study were the notification and non-prosecution procedure, euthanasia of newborns and infants, and assisted suicide in psychiatric practice. The authors of the follow-up report state that it would be desirable to reduce the number of "terminations of life without patients' request," but this must be the common responsibility of the doctor and the patient. They suggest that the person who does not wish to have his life terminated should declare this clearly, in advance, verbally and in writing, preferably in the form of a living will. Involuntary euthanasia was rampant in 1990 and equally rampant in 1995. The author concludes that Dutch doctors who practice euthanasia are not on the slippery slope. From the very beginning, they have been at the bottom.


End of life decisions in mentally disabled people [editorial]
van-der-Maas-P
BMJ. 1997 Jul 12; 315(7100): 73


Physician-assisted suicide and euthanasia in the Netherlands. Lessons from the Dutch
Hendin-H; Rutenfrans-C; Zylicz-Z
JAMA. 1997 Jun 4; 277(21): 1720-2


Active voluntary euthanasia or physician-assisted suicide?
Onwuteaka-Philipsen-BD; Muller-MT; van-der-Wal-G; van-Eijk-JT; Ribbe-MW
J-Am-Geriatr-Soc. 1997 Oct; 45(10): 1208-13

OBJECTIVE: To find out why Dutch general practitioners (GPs) and nursing home physicians (NHPs), and patients (according to their physician) opt for active voluntary euthanasia rather than for physician-assisted suicide, or vice-versa. DEFINITIONS: The following definitions were used in the study: Euthanasia is the intentional termination of life, by someone other than the patient, at the patient's request; physician-assisted suicide is intentionally helping a patient to terminate his or her life at his or her request. DESIGN: Two descriptive, retrospective studies. SETTING: The Netherlands. METHOD: Data were collected by means of anonymous questionnaires sent to a random sample of 521 GPs from the province of North Holland, 521 GPs from the rest of the Netherlands, and all 713 NHPs who were members of the Dutch Association of Nursing Home Physicians. Data were collected over the period 1986-1989 (inclusive) for GPs and the period 1986-June 1990 (inclusive) for NHPs. RESULTS: Forty-eight percent of the Gps, 78% of the NHPs, and about half of the patients who opted for euthanasia did so because of the physical condition of the patient. The reason GPs, NHPs, and patients gave most often for opting for physician-assisted suicide was that they wanted 'as far as possible to let the patient bear the responsibility.' CONCLUSION: In 38% of all cases for GPs and 57% of all cases for NHPs, only active voluntary euthanasia could be performed because of the patient's condition. In the other cases, where there was a choice, most GPs performed euthanasia, while most NHPs assisted in suicide. Active voluntary euthanasia was chosen primarily for medico-technical reasons, whereas physician-assisted suicide was selected primarily for moral reasons.


[The role of the consulting physician in situations of active euthanasia]
Ponsioen-BP; in-'t-Veld-CJ; van-den-Heuvel-GJ; van-Binsbergen-JJ
Ned-Tijdschr-Geneeskd. 1997 May 10; 141(19): 947-50

The cases are reported of two patients, a man aged 69 with a metastasized bronchial carcinoma and a woman aged 65 with a frontotemporal glioblastoma no longer responding to irradiation. Both requested active euthanasia. In both cases, euthanasia was performed by injection, after a general practitioner from the same locum group had acted as consultant. The requirements of meticulousness in handling a request for active euthanasia are concerned with the request (which has to be voluntary, thoroughly considered and constant), the suffering (which has to be protracted, unbearable and incurable), consultation and the written report. The consulting or second physician in cases of active euthanasia confirms that the requirements of meticulousness have been met. In addition, the second physician may assist the general practitioner in the detection of factors that may impair correct decision-making by the doctor or the patient. The second physician will be aided in performing these tasks if he is a member of the same locum group as the treating physician. However, if he considers himself too involved, a physician outside the locum group should be available at all times.


[Deliberation between physician and patient concerning active euthanasia at the patient's home]
Ponsioen-BP
Ned-Tijdschr-Geneeskd. 1997 May 10; 141(19): 921-4

Three patients, one man aged 68 and two aged 67, with terminal incurable cancer, requested euthanasia. It was performed in two, the third patient eventually died without having repeated his request. There are three phases in euthanasia: orientation (the patient asks the physician whether he would be willing to assist should the need arise), organisation (the physician ensures that the necessary prerequisites are fulfilled, i.e. the patient's request must be voluntary, mature and longlasting, his suffering must be longlasting, unbearable and incurable, and another physician must have been consulted and must have prepared a written report), and the phase entered after the definitive decision to perform euthanasia has been taken. The physician should not be reluctant to bring up the subject at an early stage, as it may set the patient's mind at rest to have expressed a wish concerning suffering and the end of life.


Retrospective study of doctors' "end of life decisions" in caring for mentally handicapped people in institutions in The Netherlands
van-Thiel-GJ; van-Delden-JJ; de-Haan-K; Huibers-AK
BMJ. 1997 Jul 12; 315(7100): 88-91

OBJECTIVES: To gain insight into the reasons behind and the prevalence of doctors' decisions at the end of life that might hasten a patient's death ("end of life decisions") in institutions caring for mentally handicapped people in the Netherlands, and to describe important aspects of the decisions making process. DESIGN: Survey of random sample of doctors caring for mentally handicapped people by means of self completed questionnaires and structured interviews. SUBJECTS: 89 of the 101 selected doctors completed the questionnaire. 67 doctors had taken an end of life decision and were interviewed about their most recent case. MAIN OUTCOME MEASURES: Prevalence of end of life decisions; types of decisions; characteristics of patients; reasons why the decision was taken; and the decision making process. RESULTS: The 89 doctors reported 222 deaths for 1995. An end of life decision was taken in 97 cases (44%); in 75 the decision was to withdraw or withhold treatment, and in 22 it was to relieve pain or symptoms with opiates in dosages that may have shortened life. In the 67 most recent cases with an end of life decision the patients were mostly incompetent (63) and under 65 years old (51). Only two patients explicitly asked to die, but in 23 cases there had been some communication with the patient. In 60 cases the doctors discussed the decision with nursing staff and in 46 with a colleague. CONCLUSIONS: End of life decisions are an important aspect of the institutionalised care of mentally handicapped people. The proportion of such decisions in the total number of deaths is similar to that in other specialties. However, the discussion of such decisions is less open in the care of mental handicap than in other specialties. Because of distinctive features of care in this specialty an open debate about end of life decisions should not be postponed.


Physician-assisted death in psychiatric practice in the Netherlands
Groenewoud-JH; van-der-Maas-PJ; van-der-Wal-G; Hengeveld-MW; Tholen-AJ; Schudel-WJ; van-der-Heide-A
N-Engl-J-Med. 1997 Jun 19; 336(25): 1795-801

BACKGROUND: In 1994 the Dutch Supreme Court ruled that in exceptional instances, physician-assisted suicide might be justifiable for patients with unbearable mental suffering but no physical illness. We studied physician-assisted suicide and euthanasia in psychiatric practice in the Netherlands. METHODS: In 1996, we sent questionnaires to 673 Dutch psychiatrists - about half of all such specialists in the country - and received 552 responses from the 667 who met the study criteria (response rate, 83 percent). We estimated the annual frequencies of requests for physician-assisted suicide by psychiatrists and actual instances of assistance. RESULTS: Of the respondents, 205 (37 percent) had at least once received an explicit, persistent request for physician-assisted suicide and 12 had complied. We estimate there are 320 requests a year in psychiatric practice and 2 to 5 assisted suicides. Excluding those who had ever assisted, 345 of the respondents (64 percent) thought physician-assisted suicide because of a mental disorder could be acceptable, including 241 who said they could conceive of instances in which they themselves would be willing to assist. The most frequent reasons for refusing were the belief that the patient had a treatable mental disorder, opposition to assisted suicide in principle, and doubt that the suffering was unbearable or hopeless. Most, but not all, patients who had been assisted by their psychiatrists in suicide had both a mental disorder and a serious physical illness, often in a terminal phase. Thirty percent of the respondents had been consulted at least once by a physician in another specialty about a patient's request for assisted death. The annual number of such consultations was estimated at 310, about 3 percent of the estimated 9700 requests for euthanasia or physician-assisted suicide in medical practice. CONCLUSIONS: Explicit requests for physician-assisted suicide are not uncommon in psychiatric practice in the Netherlands, but these requests are rarely granted. Psychiatric onsultation for medical patients who request physician-assisted death is relatively rare.


Dutch euthanasia rules relaxed
Sheldon-T
BMJ. 1997 Feb 1; 314(7077): 325



Euthanasia in family practice in The Netherlands. Toward a better understanding.
Verhoef-MJ; van-der-Wal-G
Can-Fam-Physician. 1997 Feb; 43: 231-7

OBJECTIVE: To describe the incidence of euthanasia and assisted suicide in family practice in the Netherlands, the reasons for its practice, and the characteristics of patients and physicians involved. DESIGN: Cross-sectional survey of a random sample of Dutch family physicians. SETTING: General practices in The Netherlands. PARTICIPANTS: An anonymous questionnaire was mailed to 1042 general practitioners. Of the 996 eligible physicians, 667 (67%) completed the questionnaire. MAIN OUTCOME MEASURES: Reported practices and beliefs concerning euthanasia and assisted suicide. RESULTS: In the course of an average year, 24% of Dutch family physicians had practised euthanasia or assisted suicide. Most deaths took place at home in the presence of others. According to the physicians, the most important reasons for the request were futile suffering, fear or avoidance of loss of dignity, and unbearable suffering. Euthanasia or assisted suicide was mostly (85%) administered to patients with malignant neoplasms. Physicians were more opposed to euthanasia and assisted suicide if they had never practised it, if they had a religious affiliation, and if they were older. CONCLUSIONS: This study presents empiric data about euthanasia and assisted suicide in the context of a permissive euthanasia policy. Understanding Dutch practices could be helpful for Canadians. However, each country needs to resolve these issues in its own way.


Euthanatics: implementation of a protocol to standardise euthanatics among pharmacists and GPs.
Onwuteaka-Philipsen-BD; Muller-MT; van-der-Wal-G
Patient-Educ-Couns. 1997 Jun; 31(2): 131-7

The purpose of this study was to evaluate the implementation of a protocol to standardise euthanatics among pharmacists and general practitioners (GPs). Data over 1993 and 1994 were collected by means of an anonymous postal questionnaire sent to all pharmacists (n = 37) and all GPs (n = 283) working in the area in which the protocol was implemented. In total, 76% of the pharmacists and 63% of the GPs responded. All pharmacists and 65% of the GPs were aware of the existence of the protocol and all pharmacists and 42% of the GPs were also familiar with the content of the protocol. Both pharmacists and GPs had fairly positive attitudes towards the importance and possibility of the standardisation of euthanatics. Of the GPs who performed euthanasia or assisted with suicide during the research period, 59% made use of one or more standard packages. The majority of pharmacists and GPs were satisfied with the standard packages, and all GPs indicated that they intend to use the packages again in the future. This study shows that the implementation of standardised euthanatics was quite successful.


Euthanasia and physician-assisted suicide in the Netherlands
van-der Maas-PJ, van-der-Wal-G
N Engl J Med 1997; 336: 1386-7

1996


Voluntary active euthanasia and doctor-assisted suicide: knowledge and attitudes of Dutch medical students.
Muller-MT; Onwuteaka-Philipsen-BD; Kriegsman-DM; van-der-Wal-G
Med-Educ. 1996 Nov; 30(6): 428-33

The objective of the study was to gain insight into the knowledge of and attitudes towards voluntary active euthanasia and doctor-assisted suicide (EEDAS) of Dutch medical students, and to determine whether knowledge and attitudes change after a 1-day informative conference about EDAS. Data were collected by means of two self-administered questionnaires. Questionnaire 1 had to be completed before the start of the conference and questionnaire 2 after the conference. In both questionnaires, students were asked by means of two open-ended questions to define euthanasia and doctor-assisted suicide. They were also asked to indicate which of eight statements met with the requirements for prudent practice. Finally, the students were asked to what extent they agreed or disagreed with each of seven statements about attitudes towards EDAS. To determine if a selection occurred among students who returned both questionnaires, their background characteristics, and knowledge and attitudes towards EDAS were compared with those who returned only the first questionnaire. Forty-seven students returned only the first questionnaire, while both questionnaires were returned by 137 students. No differences were found between students who returned both questionnaires and those who returned only the first questionnaire with regard to age, religion, knowledge of and attitudes towards EDAS. Students' knowledge of the definitions of EDAS and the requirements for prudent practice improved significantly. Students' reactions to the statements on attitudes towards EDAS showed that a large majority had a fairly positive attitude towards EDAS. There was no significant difference before and after the conference. Male students and students with a religion were more opposed to EDAS than female students and students without a religion. The fact that the students' knowledge of EDAS improved after a 1-day conference does not imply sufficient understanding of the issue. Because EDAS is allowed only under strict conditions in the Netherlands, medical tudents require special training. Only then will they be equipped to deal with requests for EDAS during their future careers.


Evaluation of the notification procedure for physician-assisted death in the Netherlands
van-der-Wal-G; van-der-Maas-PJ; Bosma-JM; Onwuteaka-Philipsen-BD; Willems-DL; Haverkate-I; Kostense-PJ
N-Engl-J-Med. 1996 Nov 28; 335(22): 1706-11

BACKGROUND: In the Netherlands, a notification procedure for physician-assisted death has been in use since 1991. It requires doctors to report each case to the coroner, who in turn notifies the public prosecutor. Ultimately, the Assembly of Prosecutors General decides whether to prosecute. Although physician-assisted death remains technically illegal, doctors are extremely unlikely to be prosecuted if they comply with the requirements for accepted practice. In 1995, the ministers of health and justice commissioned an evaluation to determine the adequacy of the notification procedure. METHODS: A random sample of 405 physicians were interviewed. We also interviewed 147 physicians who had reported cases of physician-assisted death and 116 coroners, and we reviewed 353 judicial files of reported cases. In addition, we interviewed 48 public prosecutors and reviewed the minutes of the Assembly of Prosecutors General for 1991 to 1995 and all published court decisions from 1981 through 1995. RESULTS: In 1995, about 41 percent of all cases of euthanasia and physician-assisted suicide were reported. There were no major differences between reported and unreported cases in terms of the patients' characteristics, clinical conditions, or reasons for the action. Most patients had cancer and were described as suffering "unbearably" and 'hopelessly." Of the 6324 cases reported during the period from 1991 through 1995, only 13 involved prosecution of the physician. The majority of respondents in the groups interviewed thought that all cases of physician-assisted death should be reviewed, although most doctors thought the review should be performed by other doctors, and there was substantial concern about the burden associated with the reporting procedure. CONCLUSIONS: Substantial progress in the oversight of physician-assisted death has been achieved in the Netherlands. The reporting procedure could be more streamlined and less threatening.


Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995
van-der-Maas-PJ; van-der-Wal-G; Haverkate-I; de-Graaff-CL; Kester-JG; Onwuteaka-Philipsen-BD; van-der-Heide-A; Bosma-JM; Willems-DL
N-Engl-J-Med. 1996 Nov 28; 335(22): 1699-705

BACKGROUND: In 1991 a new procedure for reporting physician-assisted deaths was introduced in the Netherlands that led to a tripling in the number of reported cases. In 1995, as part of an evaluation of this procedure, a nationwide study of euthanasia and other medical practices concerning the end of life was begun that was identical to a study conducted in 1990. METHODS: We conducted two studies, the first involving interviews with 405 physicians (general practitioners, nursing home physicians, and clinical specialists) and the second involving questionnaires mailed to the physicians attending 6060 deaths that were identified from death certificates. The response rates were 89 percent and 77 percent, respectively. RESULTS: Among the deaths studied, 2.3 percent of those in the interview study and 2.4 percent of those in the death-certificate study were estimated to have resulted from euthanasia, and 0.4 percent and 0.2 percent, respectively, resulted from physician-assisted suicide. In 0.7 percent of cases, life was ended without the explicit, concurrent request of the patient. Pain and symptoms were alleviated with doses of opioids that may have shortened life in 14.7 to 19.1 percent of cases, and decisions to withhold or withdraw life-prolonging treatment were made in 20.2 percent. Euthanasia seems to have increased in incidence since 1990, and ending of life without the patient's explicit request to have decreased slightly. For each type of medical decision except those in which life-prolonging treatment was withheld or withdrawn, cancer was the most frequently reported diagnosis. CONCLUSIONS: Since the notification procedure was introduced, end-of-life decision making in the Netherlands has changed only slightly, in an anticipated direction. Close monitoring of such decisions is possible, and we found no signs of an unacceptable increase in the number of decisions or of less careful decision making.


Euthanasia in the Netherlands--good news or bad? [editorial]
Angell-M
N-Engl-J-Med. 1996 Nov 28; 335(22): 1676-8


Teaching euthanasia: the integration of the practice of euthanasia into the grief, death, and dying curricula of postgraduate family medicine training.
Kimsma-GK; van-Duin-BJ
Camb-Q-Healthc-Ethics. 1996 Winter; 5(1): 107-12


Euthanasia in the Netherlands: the role of the Dutch medical profession.
Dillmann-RJ
Camb-Q-Healthc-Ethics. 1996 Winter; 5(1): 100-6


Euthanasia in the Netherlands.
ten-Have-HA; Welie-JV
Crit-Care-Clin. 1996 Jan; 12(1): 97-108

A review of two decades of euthanasia advocacy reveals that the arguments in favor of euthanasia are not consistent. Although the Dutch debate on euthanasia started as a protest against contemporary medicine's power over death and dying, the general acceptance of euthanasia and recent litigation may have increased medical power by shifting the balance further in the direction of physicians. This article argues that the anxieties of some of the opponents of a euthanasia bill were justified.


Euthanasia: going Dutch?
Twycross-RG
J-R-Soc-Med. 1996 Feb; 89(2): 61-3

My experience in 25 years as a hospice doctor have reinforced my belief that when everything is taken into account--physical, psychological, social and spiritual--euthanasia is not the answer. This belief is enhanced by what I see happening in the Netherlands. However, lest it be thought that I have become hardened and indifferent to suffering let me add that, although firmly opposed to euthanasia, I consider that: (i) a doctor who has never been tempted to kill a patient probably has had limited clinical experience or is not able to empathize with those who suffer (ii) a doctor who leaves a patient to suffer intolerably is morally more reprehensible than the doctor who performs euthanasia A doctor has twin obligations to preserve life and to relieve suffering. Preserving life is increasingly meaningless when a terminally ill patient is close to death, and the emphasis on relieving suffering becomes paramount. Even here, however, the doctor is obliged to achieve his objective with minimum risk to the patient's life. This means that treatment to relieve pain and suffering which coincidentally might bring forward the moment of death by a few hours or days is acceptable (the principle of double effect), but administering a drug such as potassium or curare, with the primary intention of causing death, is not.


Policies on medical decisions concerning the end of life in Dutch health care institutions.
Haverkate-I; van-der-Wal-G
JAMA. 1996 Feb 14; 275(6): 435-9

OBJECTIVE--To describe the prevalence and some features of policies on medical decisions concerning the end of life (MDELs) in Dutch hospitals, nursing homes, and institutions for the mentally disabled. DESIGN--A cross-sectional descriptive postal survey of 558 Dutch health care institutions. SETTING--All Dutch hospitals, nursing homes, and general institutions for the mentally disabled. PARTICIPANTS--Directors of patients care of the institutions. MAIN OUTCOME MEASURES--Respondents' reports on the existence of policies and guidelines on the following MDELs: euthanasia/assisted suicide (EAS), life-terminating acts without explicit request of the patient, refusal of treatment by patient, withholding or withdrawing treatment, symptom and pain control, and do-not-resuscitate (DNR) decisions. RESULTS--Of 558 health care institution managers, 86% responded. Most of the hospitals (69.2%) and nursing homes (73.9%) but only 16.3% of the institutions for the disabled had a written EAS policy. Nursing homes with a ban on EAS often had religious affiliations. In 37% of nursing homes, 15% of hospitals, and 15% of institutions for the disabled, the management had written policies on terminating life without request. Sixty percent of the hospitals, 35% of the nursing homes, and 17% of the institutions for the disabled had guidelines for one or more of four other distinct MDELs. Forty-five percent, 20%, and 8% of hospitals, nursing homes, and institutions of mentally disabled, respectively, had guidelines on DNR decisions. The management of 89% of the hospitals and 94% of the nursing homes communicated their policies on EAS to physicians and nurses in their institutions without being asked. Far fewer of these hospitals (3.9%) and nursing homes (30.5%) made their policies on EAS known to patients without being asked. CONCLUSIONS--This study indicates that an important step toward policy development on EAS has been made by Dutch hospitals and nursing homes. Particularly with respect to policies on such decisions as withholdin or withdrawing treatment, symptom and pain control, and DNR orders, an unexplored field is open to management for policy development in the Netherlands.


Euthanasia and physician-assisted suicide in homosexual men with AIDS
Bindels-PJ; Krol-A; van-Ameijden-E; Mulder-Folkerts-DK; van-den-Hoek-JA; van-Griensven-GP; Coutinho-RA
Lancet. 1996 Feb 24; 347(9000): 499-504

BACKGROUND: In the Netherlands a nationwide study has shown that, in 38% of deaths, there have been medical decisions concerning the end of life (MDEL); 2.1% of all deaths were brought about by euthanasia or physician- assisted suicide (PAS). We investigated the incidence of MDEL in homosexual men with AIDS, suspecting that it might be higher, and studied the effect of euthanasia/PAS on survival time. METHODS: The patients were 131 male homosexual participants in a cohort study in Amsterdam, diagnosed between 1985 and 1992 as having AIDS; all had died before Jan 1, 1995. Clinical and laboratory data and information on mode of death were obtained from their physicians and by review of hospital records. Those who died by euthanasia/PAS or in whom there had been other MDEL were then compared with those who died naturally. FINDINGS: 29 men (22%) had died by euthanasia/PAS and in 17 (13%) another MDEL had been made; thus, more than one-third of these men had made medical decisions concerning the end of life. The greatest difference between the groups was in age at time of diagnosis-72% aged 40 or more in the euthanasia/PAS group compared with 38% in the natural death group. The likelihood (relative risk) of euthanasia/PAS increased with duration of survival after AIDS diagnosis. Comparison of the groups in terms of three laboratory markers (CD4+ and CD8+ cells and phytohaemagglutinin responses) in the two years before death, and estimates of these markers at the time of death, did not indicate any substantial shortening of life by euthanasia/PAS; in the judgment of the physicians, most of these patients would have died naturally within one month. INTERPRETATION: A possible reason for the high incidence of MDEL in this cohort was a good knowledge of the characteristics of AIDS acquired through long-term awareness of HIV infection. The higher rate of euthanasia in those with long survival from AIDS diagnosis could reflect either additional suffering or the greater opportunity to discuss this option with friends and hysicians. Our findings indicate that euthanasia and other MDEL did little to shorten life; rather, they were an extreme form of palliation, applied in the terminal phase of a lethal disease.

1995


“Death on Request” and Dutch euthanasia policy.
Zylicz-Z
Prog Palliative Care 1995; 3: 43-4


The person from Porlock. Ethical issues in terminal care: the Dutch perspective
Blijham-GH
Support-Care-Cancer. 1995 Jan; 3(1): 61-5

In the Netherlands medical decisions concerning end of life (MDEL) play a role in 38% of all deaths. Euthanasia, defined as an intentional termination of life by somebody else at an individual's request, is done in 1.8% of deaths. Only 4% of Dutch physicians would never perform or refer for euthanasia, and over 50% have performed euthanasia. Around 25,000 Dutch patients per year bring up euthanasia as a possibility in case suffering becomes unbearable; around 10% will finally have euthanasia performed. On the basis of these opinions and data the Dutch legislation has recently been reformed. Euthanasia remains a crime and each case will be reviewed by the district attorney. Court decisions, however, have confirmed the view that in some cases of euthanasia the physician may be confronted with conflicting obligations and therefore will not be punished. As a consequence, cases fulfilling a number of requirements will not be prosecuted. In conclusion, MDEL including euthanasia are considered ethically justifiable and legally permissible if they are part of an open, honest and careful approach to patients with unbearable suffering, in particular in the case of cancer.


Attitudes of Dutch general practitioners and nursing home physicians to active voluntary euthanasia and physician-assisted suicide
Onwuteaka-Philipsen-BD; Muller-MT; van-der-Wal-G; van-Eijk-JT; Ribbe-MW
Arch-Fam-Med. 1995 Nov; 4(11): 951-5

OBJECTIVE: To gain insight into the attitudes of Dutch general practitioners and nursing home physicians to voluntary active euthanasia and physician-assisted suicide. DESIGN: Descriptive study. METHOD: Data were collected by means of anonymous postal questionnaires to be completed by a random sample of 521 general practitioners from the province of North Holland, 521 general practitioners from the rest of the Netherlands, and 713 Dutch nursing home physicians who were members of the Dutch Association of Nursing Home Physicians. RESULTS: The written responses of general practitioners and nursing home physicians to six statements about voluntary active euthanasia and physician-assisted suicide showed that a large majority had a fairly positive attitude to euthanasia and suicide. This finding also emerged from the scores obtained on a scale compiled on the basis of the statements. General practitioners and nursing home physicians were more opposed to euthanasia and physician-assisted suicide if they had never performed it, if they belonged to a religious group, or if they were older. CONCLUSION: Dutch general practitioners and nursing home physicians have a fairly positive attitude toward euthanasia and physician-assisted suicide. However, the majority of these physicians favor a policy of voluntary active euthanasia and physician-assisted suicide under strict conditions.


Active euthanasia and physician-assisted suicide in Dutch nursing homes: patients' characteristics.
Muller-MT; van-der-Wal-G; van-Eijk-JT; Ribbe-MW
Age-Ageing. 1995 Sep; 24(5): 429-33

We wished to obtain information about the principal and subsidiary diagnoses, sex, age, marital status, religion and background characteristics of Dutch nursing home patients to whom euthanasia/assisted suicide (EAS) was administered. We performed an exploratory, descriptive, retrospective study involving all Dutch nursing home physicians (NHPs) who in September 1990 were members of the Dutch Association of Nursing Home Physicians (NVVA; n = 713). An anonymous printed questionnaire in two parts was used. Part 1 was intended for all respondents and was expected to give insight into the nature and extent of EAS in Dutch nursing homes. Part 2 was intended only for respondents who had indicated in part 1 that they had administered EAS. They were asked to describe their last case of EAS. The study covered the period from 1986 to mid-1990. There was an 86% response. The respondents described 86 cases of EAS. Sixty-nine of these took place in a nursing home. The majority of patients to whom EAS was administered were suffering from a malignant neoplasm (53%). EAS was administered more often to men than to women. The average age of the patients was 70.9 years. When EAS was administered, the patients on average had been in the nursing home for 13.1 months. Dutch nursing home patients who were given EAS differed in various respects from 'the average nursing home patient'. The principal diagnosis for patients who were given EAS was a malignancy, whereas relatively few physically ill nursing home patients die as a result of a malignancy. The patients to whom EAS was administered were younger and more often male. EAS patients had been in the nursing home for a shorter time than the other somatic (physically disabled) patients who died during the study period.


AIDS, euthanasia and grief.
van-den-Boom-F
AIDS-Care. 1995; 7 Suppl 2: 5175-85

Almost 50% of people with AIDS in the Netherlands make the necessary arrangements for a possible death by the administration of thanatic drugs. In approximately 50% of those who arranged for it, euthanasia is performed. Euthanasia is a well-considered decision. By means of euthanasia people with AIDS want to prevent unbearable suffering and a degrading existence. Those who have arranged for euthanasia were proven to have adapted to the disease better than those who had not. No relationship was found between ending life by means of euthanasia and complicated grief in survivors. However, if the euthanasia process itself was complicated, the risk of complicated grief increased.


Euthanasia, assisted suicide and AIDS.
Laane-HM
AIDS-Care. 1995; 7 Suppl 2: S163-7

Euthanasia is the termination of the life of a patient by a doctor at the request of the patient. Over the past 15 years AIDS has become the most common cause of death among men aged 20-50 years in Amsterdam. It follows from this that in Amsterdam euthanasia and assisted suicide among PWAs is seen relatively frequently, considerably more frequently than among patients with other diseases. This paper examines the existing data on suicide and euthanasia in relation to HIV. The calculated overall incidence of euthanasia/assisted suicide among PWAs in Amsterdam is about 26%. Reasons for the procedure, drugs used and outcomes are discussed, with specific reference to the Dutch context within which these occur.


The person from Porlock. Ethical issues in terminal care: the Dutch perspective
Blijham-GH
Support-Care-Cancer. 1995 Jan; 3(1): 61-5

In the Netherlands medical decisions concerning end of life (MDEL) play a role in 38% of all deaths. Euthanasia, defined as an intentional termination of life by somebody else at an individual's request, is done in 1.8% of deaths. Only 4% of Dutch physicians would never perform or refer for euthanasia, and over 50% have performed euthanasia. Around 25,000 Dutch patients per year bring up euthanasia as a possibility in case suffering becomes unbearable; around 10% will finally have euthanasia performed. On the basis of these opinions and data the Dutch legislation has recently been reformed. Euthanasia remains a crime and each case will be reviewed by the district attorney. Court decisions, however, have confirmed the view that in some cases of euthanasia the physician may be confronted with conflicting obligations and therefore will not be punished. As a consequence, cases fulfilling a number of requirements will not be prosecuted. In conclusion, MDEL including euthanasia are considered ethically justifiable and legally permissible if they are part of an open, honest and careful approach to patients with unbearable suffering, in particular in the case of cancer.

1994


Mental suffering as justification for euthanasia in the Netherlands
Spanjer-M
Lancet 1994; 343:1630


Euthanasia in Holland: an ethical critique of the new law.
Jochemsen-H
J-Med-Ethics. 1994 Dec; 20(4): 212-7

In the Netherlands the government's proposal for the legal regulation of euthanasia, assisted suicide and the termination of a patient's life without request has been approved by Parliament. The defence of this proposal is to a large extent based on a specific interpretation of data about the practice of euthanasia in that country, published in 1991 (the Remmelink Report). This paper discusses both the interpretation of the data and the new law. On the basis of that and other data, the author concludes that many cases of euthanasia, assisted suicide and termination of a patient's life without request remain unnotified and therefore unreviewed by the legal authorities. It is argued that the new law will not guarantee an improvement to this situation. In short, the new law will not protect effectively the lives of patients, and must, therefore, be open to ethical and legal objection.


Euthanasia in The Netherlands.
van-der-Wal-G; Dillmann-RJ
BMJ. 1994 May 21; 308(6940): 1346-9

The practice of euthanasia in the Netherlands is often used as an argument in debates outside the Netherlands--hence a clear description of the Dutch situation is important. This article summarises recent data and discusses conceptual issues and relevant characteristics of the system of health care. Special emphasis is put on regulation, including relevant data on notification and prosecution. Besides the practice of euthanasia the Dutch are confronted with the gaps in reporting of cases to the public prosecutor and the existence of cases of ending a life without an explicit request. Nevertheless, the "Dutch experiment" need not inevitably lead down the slippery slope because of the visibility and openness of this part of medical practice. This will lead to increased awareness, more safeguards, and improvement of medical decisions concerning the end of life.


Voluntary active euthanasia and physician-assisted suicide in Dutch nursing homes: are the requirements for prudent practice properly met?
Muller-MT; Van-der-Wal-G; van-Eijk-JT; Ribbe-MW
J-Am-Geriatr-Soc. 1994 Jun; 42(6): 624-9

OBJECTIVE: To acquire data about and an understanding of the way in which Dutch nursing home physicians (NHPs) who administer voluntary active euthanasia and/or physician-assisted suicide (EAS) cope with the requirements for prudent practice. These requirements include: the patient must experience his or her suffering as unbearable and hopeless; the wish to die must be well considered and persistent; the request must be voluntary; the NHP must consult at least one other physician; the physician is not allowed to issue a certificate testifying to natural death and is obliged to keep records. DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS: See preceding paper. RESULTS: Sixty-nine NHPs (12%) indicated that they had administered EAS on at least one occasion. The state of the patient was described by the NHP as utterly hopeless in 88% of cases and as utterly unbearable in 64% of the cases. The period of time between the first discussion of the subject and the actual administration varied from less than a day to more than a year. The most frequently given reasons for the request were unbearable suffering (53%) and hopeless suffering (49%). The majority of the NHPs (85%) indicated that it was the patient who first broached the subject of EAS. Eighty-five percent of the NHPs also requested a consultation with another physician. In the majority of cases this second opinion was given by another NHP (63%); over 50% of these NHPs worked in the same nursing home. Ninety-one percent of the physicians consulted were convinced that the request was well considered, and 93% found that there was no alternative treatment available. The nurses involved were consulted informally: 94% were questioned about the request for EAS and 93% about the physician's intention to comply. Seventy-five percent of the respondents said they had made some sort of written notes regarding the last time they had administered EAS. The number of certificates testifying to death by natural causes fell after 1988. In 41% of the cases all requirements were me. CONCLUSION: The results of this study indicate that Dutch NHPs observe all the requirements for EAS in 41% of cases. In the remaining cases, shortcomings were found: NHPs allowed too little time between the first discussion and the actual administration; they did not always keep written records; or they signed a death certificate testifying that the patient had died a natural death.


Voluntary active euthanasia and physician-assisted suicide in Dutch nursing homes: requests and administration
Van-der-Wal-G; Muller-MT; Christ-LM; Ribbe-MW; van-Eijk-JT
J-Am-Geriatr-Soc. 1994 Jun; 42(6): 620-3

AB: OBJECTIVE: To learn how many requests for voluntary active euthanasia and/or physician-assisted suicide (EAS) are made to Dutch nursing home physicians (NHPs) and how often these requests are honored. DESIGN: Retrospective survey. SETTING: The Netherlands. PARTICIPANTS: All Dutch NHPs affiliated with the Dutch Association of Nursing Home Physicians (n = 713). MEASUREMENTS: An anonymous postal questionnaire was sent to all Dutch NHPs affiliated with the Dutch Association of Nursing Home Physicians (n = 713). Respondents were asked how often they had received an explicit request for EAS and whether they had complied with that request. Those who had complied were asked questions about the last occasion on which they had administered either voluntary active euthanasia or physician-assisted suicide. RESULTS: The response rate was 86% (n = 582). Of the respondents, 88% had never administered EAS in nursing homes. The remaining 12% (n = 69) had received 164 requests for voluntary active euthanasia and 53 requests for physician-assisted suicide in the period 1986 through mid-1990. Of these requests, 74 were granted (51 voluntary active euthanasia and 23 physician-assisted suicide). Dutch NHPs together receive an average of 300 requests for EAS a year. They comply with 25 of such requests annually. CONCLUSION: Not many requests for EAS are made in Dutch nursing homes. Of these requests, fewer than 1 in 10 result in the actual administration of EAS. The data presented are relatively constant for the 4.5-year period studied.


[Life-terminating actions by family practitioners and nursing home physicians without the patient's request]
Muller-MT; van-der-Wal-G; Ribbe-MW; van-Eijk-JT
Ned-Tijdschr-Geneeskd. 1994 Feb 19; 138(8): 395-8

OBJECTIVE. To describe deliberate and active termination of life without the patient's request by general practitioners and Dutch 'nursing home' physicians. DESIGN. Descriptive, retrospective investigation. METHOD. Data were collected through anonymous postal questionnaires sent to a random sample of 521 general practitioners in North Holland and 521 general practitioners in the rest of the Netherlands regarding 1986-1989 and to all 713 Dutch 'nursing home' physicians affiliated to the Dutch Association of Nursing Home Physicians regarding 1986-June 1990. RESULTS. 65 General practitioners (10%) and 28 nursing home physicians (5%) had at any time deliberately terminated the life of a patient without explicit request by the patient, 94 and 70 times, respectively. In almost all cases the general practitioners indicated that the patients were suffering intensely; the nursing home physicians indicated this in 65% of the cases; with 66% and 57% of the patients contact was not possible; in 50% and in 65% of the cases, respectively, the family was involved in the decision to terminate the patient's life. CONCLUSION. Termination of life without request by the patient occurs in the practices of Dutch general practitioners and Dutch 'nursing home' physicians, but is rare.


Nationwide study of decisions concerning the end of life in general practice in The Netherlands.
Pijnenborg-L; van-Delden-JJ; Kardaun-JW; Glerum-JJ; van-der-Maas-PJ
BMJ. 1994 Nov 5; 309(6963): 1209-12

OBJECTIVE--To gain insight into decisions made in general practice about the end of life. DESIGN--Study I: interviews with 405 physicians. Study II: analysis of death certificates with data obtained on 5197 cases in which decisions about the end of life may have been made. Study III: prospective study with doctors from study I: questionnaires used to collect information about 2257 deaths. The information was representative for all deaths in the Netherlands. RESULTS--Over two fifths of all patients in the Netherlands die at home. General practitioners took fewer decisions about the end of life than hospital doctors and doctors in nursing homes (34%, 40%, and 56% of all dying patients, respectively). Specifically, decisions to withhold or withdraw treatment to prolong life were taken less often. Euthanasia or assisted suicide, however, was performed in 3.2% of all deaths in general practice compared with 1.4% in hospital practice. In over half of the cases concerning pain relief or non-treatment general practitioners did not discuss the decision with the patient, mostly because of incapacity of the patient, but in 20% of cases for "paternalistic" reasons. Older general practitioners discussed such decisions less often with their patients. Colleagues were consulted more often if the general practitioner worked in group practice. CONCLUSION--Differences in work situation between general practitioners and hospital doctors and differences between the group of general practitioners contribute to differences in the number and type of decisions about the end of life as well as in the decision making process.

1993


Euthanasia policy in The Netherlands: the role of consultation-liaison psychiatrists.
Huyse-FJ; van-Tilburg-W
Hosp-Community-Psychiatry. 1993 Aug; 44(8): 733-8

The authors describe national guidelines introduced in the Netherlands in late 1990 for carrying out euthanasia requests by medically ill patients. In about 49,000 of the 130,000 annual deaths in that country, doctors make a decision that may influence the duration of life. In 2,300 cases doctors perform euthanasia. Thus euthanasia accounts for 1.8 percent of all deaths and 5 percent of the cases in which doctors' decisions play a role. The authors point out cultural differences between the U.S. and the Netherlands, such as in access to health care and in social tolerance and pragmatism, that should be considered by American policymakers who address the issue of euthanasia. The role of Dutch consultation-liaison psychiatrists in euthanasia was assessed by a survey of members of the Netherlands Consortium of Consultation/Liaison Psychiatry. Most felt that involvement of psychiatrists in such cases should not be mandatory and that their most important role was to assess patients' decision-making capacity. Half of the psychiatrists felt that their role was to support the decision-making process of the ward staff.


Life-terminating acts without explicit request of patient
Pijnenborg-L; van-der-Maas-PJ; van-Delden-JJ; Looman-CW
Lancet. 1993 May 8; 341(8854): 1196-9

In the Dutch nationwide study on medical decisions concerning the end of life (MDEL) life-terminating acts without the explicit request of the patient (LAWER) were noted in 0.8% of all deaths. We present here quantitative information and a discussion of the main issues raised by LAWER. In 59% of LAWER the physician had some information about the patient's wish; in 41% discussion on the decision would no longer have been possible. In LAWER patients tend to be younger and more likely to be male and to have cancer than in non-acute deaths generally. The physician (specialist or general practitioner) knew the patient on average 2.4 years and 7.2 years, respectively. Life was shortened by between some hours and a week at most in 86%. In 83% the decision has been discussed with relatives and in 70% with a colleague. In nearly all cases, according to the physician, the patient was suffering unbearably, there was no chance of improvement, and palliative possibilities were exhausted. MDEL probably will increase in number in future but interviews with Dutch physicians suggest a possible fall in LAWER, even though there will always be some situations in which a well-considered LAWER decision may have to be made.


[The Remmelink report is not the only source. Cryptothanasia in the Netherlands--sufficiently documented]
Bischofberger-E
Lakartidningen. 1993 May 19; 90(20): 1924-5


Euthanasia in The Netherlands. General practice facts.
van-Weel-C
Aust-Fam-Physician. 1993 Apr; 22(4): 537, 540-1

The recent survey of the way general practitioners act in case of euthanasia, did point to the fact that procedural requirements were not always observed. This concerned particularly the issuing of an appropriate death certificate. It is important that the practice of euthanasia be prudently surveyed in order to safeguard the standard of euthanasia that general practitioners are able to provide. Fear in the community for unwanted medical practice is understandable when the history of Hitler Germany is used as a frame of reference. Stories of mercy killing in nursing homes or elsewhere will as well increase anxiety. This fear is, however, based on a wrong understanding of euthanasia. The formulated requirements and prudent surveillance offer the best protection against the fear of the community.

1992

Life-prolonging and life-terminating treatment of severely handicapped newborn babies: a discussion of the Report of the Royal Dutch Society of Medicine on "Life-Terminating Actions with Incompetent Patients: Part I: Severely Handicapped Newborns".
Jochemsen-H
Issues-Law-Med. 1992 Fall; 8(2): 167-81


[The use of drugs for euthanasia and assisted suicide in family practice]
van-der-Wal-G; van-Eijk-JT; Leenen-HJ; Spreeuwenberg-C
Ned-Tijdschr-Geneeskd. 1992 Jul 3; 136(27): 1299-305

An exploratory, descriptive, retrospective study was carried out concerning the use of means for euthanasia or assisted suicide, primarily regarding the period 1986-1989. Data were collected via an anonymous written inquiry among a random sample of family physicians in North Holland (n = 521) and family physicians in the rest of the Netherlands (n = 521). The inquiry contained among others questions about the last case they had encountered. In addition, police reports of euthanasia or assisted suicide administered by family physicians in North Holland (n = 263) were analysed. The response to the inquiry was 67%; (non-respondents did not differ from respondents): 388 cases could be analysed. The use of euthanatics by family physicians in North Holland and those in the rest of the Netherlands was identical. More than 40 different euthanatics were used, most of them incidentally. The most frequently used (combination of) means were a benzodiazepine with a neuromuscular relaxant (23%), a barbiturate with a neuromuscular relaxant (20%), barbiturates (15%) and opioids (12%). Most euthanatics were given intravenously (61%, of which 5% by infusion), orally 21%, intramuscularly 12%, rectally 3% and subcutaneously 2%. The quantities applied varied greatly. The average length of time from the start of the procedure till decrease was 3.8 hours (less than or equal to 1 minute-72 hours). In 12% of the cases complications or unintended effects were reported. Comparison of inquiry and police reports showed some differences.

Euthanasia and assisted suicide. II. Do Dutch family doctors act prudently?
Van-der-Wal-G; van-Eijk-JT; Leenen-HJ; Spreeuwenberg-C
Fam-Pract. 1992 Jun; 9(2): 135-40

We conducted a survey among two random samples of Dutch doctors in order to determine whether they acted prudently with regard to euthanasia and assisted suicide. The doctors completed an anonymous questionnaire and those who at one time or another had applied euthanasia or assisted suicide (52%) were asked about several aspects of the requirements for prudent practice. 'Pointless suffering' was the most important and most common reason for requesting euthanasia or assisted suicide; 'pain' was rarely the most important reason. In 7% of the cases alternative forms of treatment were still available; these were hardly ever therapeutic. A total of 12% of the doctors had applied euthanasia or assisted suicide without having had any kind of consultation or discussion with a colleague, a nurse or any other health care professional; 26% had not issued a certificate testifying to death from natural causes. We conclude that some of the family doctors do not observe the procedural requirements, but that the majority satisfies the material requirements for prudent practice.



Euthanasia and assisted suicide. I. How often is it practised by family doctors in The Netherlands?
van-der-Wal-G; van-Eijk-JT; Leenen-HJ; Spreeuwenberg-C
Fam-Pract. 1992 Jun; 9(2): 130-4

A survey was conducted among family doctors to determine the frequency with which they were requested to administer euthanasia or assist in suicide, and how often they actually applied these procedures. Two random samples (in each n = 521) were taken from the population of Dutch family doctors (n = 6300) and requested to complete an anonymous questionnaire. The response was 67%. The entire body of Dutch family doctors practices euthanasia or assisted suicide about 2000 times per annum; 48% have never engaged in these practices. An average of 40% of all requests are complied with. We conclude that far fewer family doctors are involved in euthanasia and assisted suicide than was previously supposed. Euthanasia or assisted suicide was administered to 1 in 25 persons who died in their own homes.


[Life-terminating activities without express request by the patient and the viewpoint of the cabinet in relation to medical decisions concerning life's end]
van-Delden-JJ
Ned-Tijdschr-Geneeskd. 1992 Mar 28; 136(13): 644-8

1991

Report of the Royal Dutch Society of Medicine on "Life-terminating actions with incompetent patients, Part I: Severely handicapped newborns".
Issues-Law-Med. 1991 Winter; 7(3): 365-7


Euthanasia and other medical decisions concerning the end of life
Van-Der-Maas-PJ; Van-Delden-JJ; Pijnenborg-L; Looman-CW
Lancet. 1991 Sep 14; 338(8768): 669-74

This article presents the first results of the Dutch nationwide study on euthanasia and other medical decisions concerning the end of life (MDEL). The study was done at the request of the Dutch government in preparation for a discussion about legislation on euthanasia. Three studies were undertaken: detailed interviews with 405 physicians, the mailing of questionnaires to the physicians of a sample of 7000 deceased persons, and the collecting of information about 2250 deaths by a prospective survey among the respondents to the interviews. The alleviation of pain and symptoms with such high dosages of opioids that the patient's life might be shortened was the most important MDEL in 17.5% of all deaths. In another 17.5% a non-treatment decision was the most important MDEL. Euthanasia by administering lethal drugs at the patient's request seems to have been done in 1.8% of all deaths. Since MDEL were taken in 38% of all deaths (and in 54% of all non-acute deaths) we conclude that these decisions are common medical practice and should get more attention in research, teaching, and public debate.


Euthanasia.
Gunning-KF
Lancet 1991; 338:1010


Euthanasia.
Zylicz-Z
Lancet 1991; 338:1150


[Euthanasia and assisted suicide by physicians in the home situation. 2. Suffering of the patients]
van-der-Wal-G; van-Eijk-JT; Leenen-HJ; Spreeuwenberg-C
Ned-Tijdschr-Geneeskd. 1991 Aug 31; 135(35): 1599-603

In order to assess the suffering of patients who died at home and with whom family doctors participated in euthanasia or assisted suicide, an exploratory, descriptive, retrospective study was carried out regarding primarily the period 1986-1989. Data were collected via anonymous written inquiry among an at random sample of family doctors in North Holland (n = 521), and family doctors in the rest of the Netherlands (n = 521). With reference to the last case of euthanasia or assisted suicide they had encountered questions were included about physical and emotional suffering, signs and symptoms and life expectation. Correlations and differences were analysed by means of the chi2-test. The response to the inquiry was 67% (non-responders did not otherwise differ from responders): 228 (North Holland), 160 (rest of the Netherlands) cases could be analysed. Most patients suffered physically as well as emotionally. The most frequently mentioned aspect was 'general weakness or tiredness'. Also 'dependence or being in need of help', loss of dignity, humiliation' and 'pain' were often present to a (very) large extent. At the time the procedure was carried out the life expectation in almost two-thirds of the cases was less than 2 weeks; in 10% of the cases it was more than 3 months. For several reasons, this investigation reduces the possibilities of extrapolation. Further investigation is necessary to determine whether this picture of suffering is specific of this category of patients.


[Euthanasia and assisted suicide by physicians in the home situation. I. Diagnoses, age and sex of patients]
van-der-Wal-G; van-Eijk-JT; Leenen-HJ; Spreeuwenberg-C
Ned-Tijdschr-Geneeskd. 1991 Aug 31; 135(35): 1593-8

In order to map out morbidity, age and sex of patients with whom family doctors participated in euthanasia or assisted suicide, an exploratory, descriptive, retrospective study was carried out primarily regarding the period 1986-1989. Data were collected via an anonymous written injury among an at random sample of family doctors in North Holland (n = 521), and family doctors in the rest of the Netherlands (n = 521). In addition, police reports of euthanasia/assisted suicide administered by family doctors in North Holland (n = 263) were analysed. The inquiry included among others questions about the last case doctors had encountered. Diagnoses were classified according to the ICD-9. The results were compared with compiled mortality data relating to persons who died in their own homes. Correlations and differences were analysed by means of the chi2-test. The response to the inquiry was 67% (non-responders did not otherwise differ from responders): 228 (North Holland), 160 (rest of the Netherlands) and 263 (police reports) cases could be analysed. Of the patients, 85% suffered from a malignant neoplasm. The average age at which euthanasia or assisted suicide was practised was 63.4 years (men) and 66.1 years (women). Under the age of 30 and above 85 euthanasia or assisted suicide was administered only rarely. Proportionally these procedures were applied to the same extent to men as to women. In about 20% of the cases an important secondary diagnosis was present. In conclusion, it is especially the malignant neoplasms that cause such suffering that euthanasia or assisted suicide are practised. The average age at which they are applied is considerably lower than that of the total of people who die in their own homes.

1990

Euthanasia in The Netherlands.
Brahams-D
Lancet. 1990 Mar 10; 335(8689): 591-2


[Medical decisions around life's end, the study by instruction of the Commission Remmelink]
van-der-Maas-PJ
Ned-Tijdschr-Geneeskd. 1990 Sep 15; 134(37): 1802-5