Dutch criteria of due care for physician-assisted dying in medical practice: a physician perspective

The Physician-Assisted Suicide Pathway in Italy: Ethical Assessment and Safeguard Approaches

Although in Italy there is currently no effective law on physician-assisted suicide or euthanasia, Decision No. 242 issued by the Italian Constitutional Court on September 25, 2019 established that an individual who, under specific circumstances, has facilitated the implementation of an independent and freely-formed resolve to commit suicide by another individual is exempt from criminal liability. Following this ruling, some citizens have submitted requests for assisted suicide to the public health system, generating a situation of great uncertainty in the application processes. As a matter of fact, shared and defined procedures are lacking as Decision 242/2019 merely added some principles on which the legislature will have to base its future intervention. This paper analyses the advisory role that the Decision attributes to territorial ethics committees with the aim of stimulating discussions on their role in oversight mechanisms. The proposed conclusion is that the envisaged role does not appear consistent with the functions of these bodies and is ultimately substantially undefined and unjustified.

Euthanasia and assisted suicide in neurological diseases: a systematic review

OBJECTIVE

To identify the neurological diseases for which euthanasia and assisted suicide are most frequently requested in the countries where these medical procedures are legal and the specific characteristics of euthanasia in some of these diseases, and to show the evolution of euthanasia figures.

METHODS

We conducted a systematic literature review.

RESULTS

Dementia, motor neuron disease, multiple sclerosis, and Parkinson's disease are the neurological diseases that most frequently motivate requests for euthanasia or assisted suicide. Requests related to dementia constitute the largest group, are growing, and raise additional ethical and legal issues due to these patients' diminished decision-making capacity. In some countries, the ratios of euthanasia requests to all cases of multiple sclerosis, motor neuron disease, or Huntington disease are higher than for any other disease.

CONCLUSIONS

After cancer, neurological diseases are the most frequent reason for requesting euthanasia or assisted suicide.

Professional experiences of formal healthcare providers in the provision of medical assistance in dying (MAiD): A scoping review

OBJECTIVE

This scoping review describes the existing literature which examines the breadth of healthcare providers' (HCP's) experiences with the provision of medical assistance in dying (MAiD).

METHOD

This study employed a scoping review methodology: (1) identify research articles, (2) identify relevant studies, (3) select studies based on inclusion/exclusion criteria, (4) chart the data, and (5) summarize the results.

RESULTS

In total, 30 papers were identified pertaining to HCP's experiences of providing MAiD. Fifty-three percent of the papers were from Europe (n = 16) and 40% of studies were from the USA or Canada (n = 12). The most common participant populations were physicians (n = 17) and nurses (n = 12). This scoping review found that HCPs experienced a variety of emotional responses to providing or providing support to MAiD. Some HCPs experienced positive emotions through helping patients at the end of the patient's life. Still other HCPs experienced very intense and negative emotions such as immense internal moral conflict. HCPs from various professions were involved in various aspects of MAiD provision such as responding to initial requests for MAiD, supporting patients and families, nursing support during MAiD, and the administration of medications to end of life.

SIGNIFICANCE OF RESULTS

This review consolidates many of the experiences of HCPs in relation to the provision of MAiD. Specifically, this review elucidates many of the emotions that HCPs experience through participation in MAiD. In addition to describing the emotional experiences, this review highlights some of the roles that HCPs participate in with relation to MAiD. Finally, this review accentuates the importance of team supports and self-care for all team members in the provision of MAiD regardless of their degree of involvement.

Physician assisted suicide in dementia: A critical review of global evidence and considerations from India

BACKGROUND

Dementias are a group of gradually progressing neurodegenerative conditions, leading to significant impairment in cognition, functioning, decision-making, capacity and autonomy. With the rise of human rights and patient-centred perspectives in psychogeriatric management, physician-assisted suicide (PAS) has emerged as an important and integral part of end-of-life care in advanced dementias.

METHODS

With only few original studies in the area, this paper takes a narrative and critical approach to review the global legislations, treatment decisions, debates as well as perspectives from patients, families and medical professionals.

RESULTS

PAS and euthanasia are legally allowed in countries like Belgium, Netherlands, Switzerland and few states of the United States (U.S.). Germany has fewer clearer legislations in this regard. The Oregon state requirement and care criteria of the Dutch euthanasia act form the basis of most such laws. Even in the presence of these provisions, PAS is fraught with multiple medical, ethical, moral and legal dilemmas and physicians as well as caregivers are quite heterogenous in their outlook. While right to live with dignity and need to end incurable suffering form the main arguments for PAS, several arguments against it are possibility of undue influence, impaired judgement leading to biased decision-making such as depression and suicidality, inappropriate assessment of capacity, and that all deaths are not necessarily painful. These dilemmas are critically discussed in light of autonomy, decision-making and advanced directives in people living with dementia as well as the rationality of ending life and 'right to live vs right to die'. Based on the findings, certain balanced strategies are highlighted for the health professionals.

CONCLUSION

The 'slippery slope' of PAS needs to be carefully evaluated from a social justice and human rights perspective to improve dignified end-of-life care in dementia. Considerations are also discussed from India, a rapidly-ageing nation with no current provisions for PAS.

Relationship Between COVID-19, Euthanasia and Old Age: A Study from a Legal-Ethical Perspective

The global pandemic situation created by COVID-19 leaves many questions open in areas as diverse as politics, economics, society and ethics. The scarcity of health resources and the use that has been made of these by some governments raises the question of whether the distribution of health resources has been equitable, or whether the allocation of health resources depended on criteria such as age. The present work investigates whether those countries or geographical areas where euthanasia is legalized, decriminalized or socially accepted, have followed selective policies limiting access to healthcare by the elderly, thus undermining what is understood as quality of life.

What the Doctor Would Prescribe: Physician Experiences of Providing Voluntary Assisted Dying in Australia

BACKGROUND

Like many countries where voluntary assisted dying (VAD) is legal, eligible doctors in Victoria, Australia, have sole legal authority to provide it. Doctors' attitudes towards legalised VAD have direct bearing on their willingness to participate in VAD and consequently, on whether permissive laws can effectively facilitate access to VAD. The study aimed to explore how some Victorian doctors are perceiving and experiencing the provision of legalised VAD under a recently commenced law.

METHODS

Semi-structured interviews with 25 Victorian doctors with no in-principle objection to legalised VAD were conducted between July 2019-February 2020. Interviews were recorded, transcribed, and analysed using thematic analysis. Ethical approval from the relevant institution was obtained.

RESULTS

Doctors perceive or experience VAD to fundamentally challenge traditional medical practice. Barriers to access to VAD derive from applicant, communication, and doctor-related factors. Doctors' willingness to participate in VAD is situation specific.

Euthanasia and assisted suicide in neurological diseases: a systematic review

OBJECTIVE

To identify the neurological diseases for which euthanasia and assisted suicide are most frequently requested in the countries where these medical procedures are legal and the specific characteristics of euthanasia in some of these diseases, and to show the evolution of euthanasia figures.

METHODS

We conducted a systematic literature review.

RESULTS

Dementia, motor neuron disease, multiple sclerosis, and Parkinson's disease are the neurological diseases that most frequently motivate requests for euthanasia or assisted suicide. Claims related to dementia constitute the largest group, are growing, and raise additional ethical and legal issues due to these patients' diminished decision-making capacity. In some countries, the ratios of euthanasia requests to all cases of multiple sclerosis, motor neuron disease, or Huntington disease are higher than for any other disease.

CONCLUSIONS

After cancer, neurological diseases are the most frequent reason for requesting euthanasia or assisted suicide.

Physician attitudes to voluntary assisted dying: a scoping review

BACKGROUND

Voluntary assisted dying (VAD) became legal in the Australian state of Victoria on 19 June 2019 and will be legal in Western Australia from 2021. Other Australian states are progressing similar law reform processes. In Australia and internationally, doctors are central to the operation of all legal VAD regimes. It is broadly accepted that doctors, as a profession, are less in favour of VAD law reform than the rest of the community. To date, there has been little analysis of the factors that motivate doctors' support or opposition to legalised VAD in Australia.

AIM

To review all studies reporting the attitudes of Australian doctors regarding the legalisation of VAD, including their willingness to participate in it, and to observe and record common themes in existing attitudinal data.

DESIGN

Scoping review and thematic analysis of qualitative and quantitative data.

DATA SOURCES

CINAHL, Embase, Scopus, PubMed and Informit were searched from inception to June 2019.

RESULTS

26 publications detailing 19 studies were identified. Thematic analysis of quantitative and qualitative findings was performed. Three overarching themes emerged. 'Attitudes towards regulation' encompassed doctors' orientation towards legalisation, the shortcomings of binary categories of support or opposition and doctors' concerns about additional regulation of their professional practices. 'Professional and personal impact of legalisation' described tensions between palliative care and VAD, and the emotional and social impact of being providers of VAD. 'Practical considerations regarding access' considered doctors' concerns about eligibility criteria and their willingness to provide VAD.

CONCLUSION

A detailed understanding of medical perspectives about VAD would facilitate the design of legislative models that take better account of doctors' concerns. This may facilitate their greater participation in VAD and help address potential access issues arising from availability of willing doctors.

Conceptual framework for assisted dying for individuals with dementia: Views of experts not opposed in principle

Dementia is one of the prominent conditions for which an aging population has been seeking end-of-life solutions such as assisted dying. Individuals with dementia, however, are often unable to meet the eligibility criteria of being mentally competent and are thus discriminated against in relation to assisted dying laws. Provided that the assisted death directive is being made in sound mind, it is still of concern whether these advance directives can be appropriately framed and safeguarded to protect the wish of these vulnerable individuals while preventing harm. Therefore, to establish consensus views of experts on primary issues of, and concerns about, assisted dying for individuals with dementia as well as exploring tentative conceptual framework to safeguard practice and application, a three-round Delphi study was conducted. A core group of 12 experts from five countries was recruited comprising expertise in domains relevant to assisted dying and dementia. A semantic-thematic approach was applied to analyze the 119 generated statements. Evaluation of these research statements resulted in full consensus of 84 (70%) items. Our primary findings highlight seven core domains: applicability of assisted dying for dementia; ethical, practical, and pathological issues regarding the application of assisted dying; and ethical, legal, and professional recommendations for the ways forward. Despite the issues surrounding the provision of assisted death for individuals with dementia, our findings lead us to cautiously conclude that devising "adequate" safeguards is achievable. The result of this research may benefit future research and practice.

Euthanasia requests in dementia cases; what are experiences and needs of Dutch physicians? A qualitative interview study

BACKGROUND

In the Netherlands, in 2002, euthanasia became a legitimate medical act, only allowed when the due care criteria and procedural requirements are met. Legally, an Advanced Euthanasia Directive (AED) can replace direct communication if a patient can no longer express his own wishes. In the past decade, an exponential number of persons with dementia (PWDs) share a euthanasia request with their physician. The impact this on physicians, and the consequent support needs, remained unknown. Our objective was to gain more insight into the experiences and needs of Dutch general practitioners and elderly care physicians when handling a euthanasia request from a person with dementia (PWD).

METHODS

We performed a qualitative interview study. Participants were recruited via purposive sampling. The interviews were transcribed verbatim, and analyzed using the conventional thematic content analysis.

RESULTS

Eleven general practitioners (GPs) and elderly care physicians with a variety of experience and different attitudes towards euthanasia for PWD were included. Euthanasia requests appeared to have a major impact on physicians. Difficulties they experienced were related to timing, workload, pressure from and expectations of relatives, society's negative view of dementia in combination with the 'right to die' view, the interpretation of the law and AEDs, ethical considerations, and communication with PWD and relatives. To deal with these difficulties, participants need support from colleagues and other professionals. Although elderly care physicians appreciated moral deliberation and support by chaplains, this was hardly mentioned by GPs.

CONCLUSIONS

Euthanasia requests in dementia seem to place an ethically and emotionally heavy burden on Dutch GPs and elderly care physicians. The awareness of, and access to, existing and new support mechanisms needs further exploration.

Medical assistance in dying: implications for health systems from a scoping review of the literature

Objective

Medical assistance in dying (MAiD) is the medical provision of substances to end a patient’s life at their voluntary request. While legal in several countries, the implementation of MAiD is met with ethical, legislative and clinical challenges, which are often overshadowed by moral discourse. Our aim was to conduct a scoping review to explore key barriers for the integration of MAiD into existing health systems.

Methods

We searched electronic databases (CINAHL, Embase, MEDLINE, and PsycINFO) and grey literature sources from 1990 to 2017. Studies discussing barriers and/or challenges to implementing MAiD from a health system’s perspective were included. Full-text papers were screened against inclusion/exclusion criteria for article selection. A thematic content analysis was conducted to summarize data into themes to highlight key implementation barriers.

Results

The final review included 35 articles (see online Appendix 1). Six categories of implementation challenges emerged: regulatory (n = 26), legal (n = 15), social (n = 9), logistical (n = 9), financial (n = 3) and compatibility with palliative care (n = 3). Within four of the six identified implementation barriers (regulatory, legal, social and logistical) were subthemes, which described barriers related to legalizing MAiD in more detail.

Conclusion

Despite multiple challenges related to its implementation, MAiD remains a requested end-of-life option, requiring careful examination to ensure adequate integration into existing health services. Comprehensive models of care incorporating multidisciplinary teams and regulatory oversight alongside improved clinician education may be effective to streamline MAiD services.

Pressure in dealing with requests for euthanasia or assisted suicide. Experiences of general practitioners

The majority of Dutch physicians feel pressure when dealing with a request for euthanasia or physician-assisted suicide (EAS). This study aimed to explore the content of this pressure as experienced by general practitioners (GP). We conducted semistructured in-depth interviews with 15 Dutch GPs, focusing on actual cases. The interviews were transcribed and analysed with use of the framework method. Six categories of pressure GPs experienced in dealing with EAS requests were revealed: (1) emotional blackmail, (2) control and direction by others, (3) doubts about fulfilling the criteria, (4) counterpressure by patient's relatives, (5) time pressure around referred patients and (6) organisational pressure. We conclude that the pressure can be attributable to the patient-physician relationship and/or the relationship between the physician and the patient's relative(s), the inherent complexity of the decision itself and the circumstances under which the decision has to be made. To prevent physicians to cross their personal boundaries in dealing with EAS request all these different sources of pressure will have to be taken into account.

Euthanasia and physician-assisted suicide not meeting due care criteria in the Netherlands: a qualitative review of review committee judgements

ObjectivesTo assess how Dutch regional euthanasia review committees (RTE) apply the euthanasia and physician-assisted suicide (EAS) due care criteria in cases where the criteria are judged not to have been met ('due care not met' (DCNM)) and to evaluate how the criteria function to set limits in Dutch EAS practice.

DESIGN

A qualitative review using directed content analysis of DCNM cases in the Netherlands from 2012 to 2016 published on the RTE website (https://www.euthanasiecommissie.nl/) as of 31 January 2017.

RESULTS

Of 33 DCNM cases identified (occurring 2012-2016), 32 cases (97%) were published online and included in the analysis. 22 cases (69%) violated only procedural criteria, relating to improper medication administration or inadequate physician consultation. 10 cases (31%) failed to meet substantive criteria, with the most common violation involving the no reasonable alternative (to EAS) criterion (seven cases). Most substantive cases involved controversial elements, such as EAS for psychiatric disorders or 'tired of life', in incapacitated patients or by physicians from advocacy organisations. Even in substantive criteria cases, the RTE's focus was procedural. The cases were more about unorthodox, unprofessional or overconfident physician behaviours and not whether patients should have received EAS. However, in some cases, physicians knowingly pushed the limits of EAS law. Physicians from euthanasia advocacy organisations were over-represented in substantive criteria cases. Trained EAS consultants tended to agree with or facilitate EAS in DCNM cases. Physicians and families had difficulty applying ambiguous advance directives of incapacitated patients.

CONCLUSION

As a retrospective review of physician self-reported data, the Dutch RTEs do not focus on whether patients should have received EAS, but instead primarily gauge whether doctors conducted EAS in a thorough, professional manner. To what extent this constitutes enforcement of strict safeguards, especially when cases contain controversial features, is not clear.

Written institutional ethics policies on euthanasia: an empirical-based organizational-ethical framework

As euthanasia has become a widely debated issue in many Western countries, hospitals and nursing homes especially are increasingly being confronted with this ethically sensitive societal issue. The focus of this paper is how healthcare institutions can deal with euthanasia requests on an organizational level by means of a written institutional ethics policy. The general aim is to make a critical analysis whether these policies can be considered as organizational-ethical instruments that support healthcare institutions to take their institutional responsibility for dealing with euthanasia requests. By means of an interpretative analysis, we conducted a process of reinterpretation of results of former Belgian empirical studies on written institutional ethics policies on euthanasia in dialogue with the existing international literature. The study findings revealed that legal regulations, ethical and care-oriented aspects strongly affected the development, the content, and the impact of written institutional ethics policies on euthanasia. Hence, these three cornerstones-law, care and ethics-constituted the basis for the empirical-based organizational-ethical framework for written institutional ethics policies on euthanasia that is presented in this paper. However, having a euthanasia policy does not automatically lead to more legal transparency, or to a more professional and ethical care practice. The study findings suggest that the development and implementation of an ethics policy on euthanasia as an organizational-ethical instrument should be considered as a dynamic process. Administrators and ethics committees must take responsibility to actively create an ethical climate supporting care providers who have to deal with ethical dilemmas in their practice.

Obligatory consultation of an independent physician on euthanasia requests in the Netherlands: what influences the SCEN physicians judgment of the legal requirements of due care?

BACKGROUND

In the Netherlands, euthanasia is allowed if physicians adhere to legal requirements. Consultation of an independent physician is one of the requirements. SCEN (Support and Consultation on Euthanasia in the Netherlands) physicians have been trained to provide such consultations.

OBJECTIVE

To study why euthanasia requests are sometimes judged not to meet requirements of due care and to find out which characteristics are associated with the SCEN physicians' judgments.

METHODS

During 5 years (2006, 2008-2011) standardized registration forms were used for data-collection. We used multilevel logistic regression analysis to assess the associations of characteristics and SCEN physicians' judgments.

RESULTS

We analyzed 1631 euthanasia requests, involving 415 SCEN physicians. Patient characteristics that were associated with a lower likelihood to meet due care requirements were: being tired with life, depression and not wanting to be a burden. Physical suffering and higher patient age were related to greater chances of meeting the requirements. There was no clear association between SCEN physicians' characteristics and their judgment.

CONCLUSION

Psychological suffering involves a greater chance that SCEN physicians judge that requirements of due care are not met. The association between SCEN physician characteristics and the judgment of euthanasia requests is limited, suggesting uniformity in their judgment.

Premises and evidence in the rhetoric of assisted suicide and euthanasia

In debates about euthanasia and assisted suicide, it is rare to find an article that begins with an expression of neutral interest and then proceeds to examine the various arguments and data before drawing conclusions based upon the results of a scholarly investigation. Although authors frequently give the impression of being impartial in their introduction, they invariably reach their prior conclusions. Positions tend to be clearly dichotomized: either one believes that the practice of euthanasia or assisted suicide is totally acceptable or completely unacceptable in a just and moral society. Where there is some admission of a gray zone of incertitude, authors attempt to persuade us that their beliefs (preferences) are the only sensible way to resolve outstanding dilemmas. The practice of vehemently promoting a "pro" or "con" position may be useful when societies must decide to either legalize certain practices or not. Although only a handful of countries have thus far accepted the legal practice of euthanasia or assisted suicide (Belgium, Luxembourg, The Netherlands, the U.S. states of Montana, Oregon, Vermont and Washington, and Switzerland), scholarly articles in recent trends mainly promote legalization, to the point of recommending expansion of the current practices. Is this a case of the philosophers being ahead of their time in promoting and rationalizing the wave of the future? Alternatively, does the small number of countries that have legalized these practices indicate a substantial gap between the beliefs and desires of common citizens and the universe of the 'abstracted realm'? For the time being, what we do know is that more countries and states are debating legalization of euthanasia or assisted suicide, the nature of laws and legal practices vary greatly and both ethical and empirical assessments of current practices are the subject of much controversy. This article presents an examination of the premises and evidence in the rhetoric of assisted suicide and euthanasia. Inasmuch as any analysis cannot be totally impartial, we do not contend that our analysis is without influence from our experiences and philosophical affinities. Notwithstanding this caveat, we venture to propose that our scrutiny of the arguments and empirical data may offer some guidance to individuals who are attempting to reach practical conclusions based upon the available evidence, whether empirical or rationalized.

Physician-assisted dying and psychiatry: recent developments in The Netherlands

The Netherlands was one of the first countries in the world to establish a legal framework for physician-assisted dying (PAD). In this article, we provide an overview of the public, political, legal, and medical debates on physician-assisted dying in The Netherlands, focusing on the role of psychiatry and mental illness. The number of individuals with chronic mental illness requesting PAD has been relatively small (although the number can be expected to increase because of the activities of various civic organizations advocating the right to die) and Dutch psychiatrists have been extremely reluctant to respond to such requests. Nevertheless, mental conditions have been central to the public debate on PAD by helping to define the nature and limits of current legislation and professional practice. Although a few Dutch psychiatrists have campaigned to increase the involvement of psychiatrists and many support PAD in principle, the majority has been hesitant to engage in PAD despite increasing public pressure.

Perspectives of decision-making in requests for euthanasia: a qualitative research among patients, relatives and treating physicians in the Netherlands

BACKGROUND

Euthanasia has been legally performed in the Netherlands since 2002. Respect for patient's autonomy is the underpinning ethical principal. However, patients have no right to euthanasia, and physicians have no obligation to provide it. Although over 3000 cases are conducted per year in the Netherlands, there is little known about how decision-making occurs and no guidance to support this difficult aspect of clinical practice.

AIM

To explore the decision-making process in cases where patients request euthanasia and understand the different themes relevant to optimise this decision-making process.

DESIGN

A qualitative thematic analysis of interviews with patients making explicit requests for euthanasia, most-involved relative(s) and treating physician.

PARTICIPANTS/SETTING

Thirty-two cases, 31 relatives and 28 treating physicians. Settings were patients' and relatives' homes and physicians' offices.

RESULTS

Five main themes emerged: (1) initiation of sharing views and values about euthanasia, (2) building relationships as part of the negotiation, (3) fulfilling legal requirements, (4) detailed work of preparing and performing euthanasia and (5) aftercare and closing.

CONCLUSIONS

A patient's request for euthanasia entails a complex process that demands emotional work by all participants. It is characterised by an intensive period of sharing information, relationship building and negotiation in order to reach agreement. We hypothesise that making decisions about euthanasia demands a proactive approach towards participants' preferences and values regarding end of life, towards the needs of relatives, towards the burden placed on physicians and a careful attention to shared decision-making. Future research should address the communicational skills professionals require for such complex decision-making.

The first five years of euthanasia legislation in Belgium and the Netherlands: description and comparison of cases

BACKGROUND

The Netherlands and Belgium legalized euthanasia in 2002.

AIM

In this study we describe and compare cases of reported euthanasia and physician-assisted suicide in the first 5 years of legislation.

DESIGN/SETTING/PARTICIPANTS

The databases of the cases reported in Belgium and the Netherlands were made available by the review committees. We compared characteristics of all cases reported between September 2002-December 2007.

RESULTS

In the Netherlands 10,319 cases were reported, in Belgium 1917. Gender and age distributions were similar in both countries. Most patients suffered from cancer (83-87%), but patients more often suffered from diseases of the nervous system in Belgium (8.3% vs. 3.9%). In the Netherlands, reported euthanasia more often occurred at home compared with Belgium (81% vs. 42%), where it occurred more often in hospital (52% vs. 9%). In the Netherlands, all cases were based on the oral request of a competent patient. In Belgium, 2.1% of the reported cases was based on an advance directive.

CONCLUSIONS

We conclude that countries debating legislation must realise that the rules and procedures for euthanasia they would agree upon and the way they are codified or not into law may influence the practice that develops once the legislation is effected or what part of that practice is reported.

Palliative treatment alternatives and euthanasia consultations: a qualitative interview study

CONTEXT

There is much debate about euthanasia within the context of palliative care. The six criteria of careful practice for lawful euthanasia in The Netherlands aim to safeguard the euthanasia practice against abuse and a disregard of palliative treatment alternatives. Those criteria need to be evaluated by the treating physician as well as an independent euthanasia consultant.

OBJECTIVES

To investigate 1) whether and how palliative treatment alternatives come up during or preceding euthanasia consultations and 2) how the availability of possible palliative treatment alternatives are assessed by the independent consultant.

METHODS

We interviewed 14 euthanasia consultants and 12 physicians who had requested a euthanasia consultation. We transcribed and analyzed the interviews and held consensus meetings about the interpretation.

RESULTS

Treating physicians generally discuss the whole range of treatment options with the patient before the euthanasia consultation. Consultants actively start thinking about and proposing palliative treatment alternatives after consultations, when they have concluded that the criteria for careful practice have not been met. During the consultation, they take into account various aspects while assessing the criterion concerning the availability of reasonable alternatives, and they clearly distinguish between euthanasia and continuous deep sedation. Most consultants said that it was necessary to verify which forms of palliative care had previously been discussed. Advice concerning palliative care seemed to be related to the timing of the consultation ("early" or "late"). Euthanasia consultants were sometimes unsure whether or not to advise about palliative care, considering it not their task or inappropriate in view of the previous discussions.

CONCLUSION

Two different roles of a euthanasia consultant were identified: a limited one, restricted to the evaluation of the criteria for careful practice, and a broad one, extended to actively providing advice about palliative care. Further medical and ethical debate is needed to determine consultants' most appropriate role.

Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study

Background

An important principle underlying the Dutch Euthanasia Act is physicians' responsibility to alleviate patients' suffering. The Dutch Act states that euthanasia and physician-assisted suicide are not punishable if the attending physician acts in accordance with criteria of due care. These criteria concern the patient's request, the patient's suffering (unbearable and hopeless), the information provided to the patient, the presence of reasonable alternatives, consultation of another physician and the applied method of ending life. To demonstrate their compliance, the Act requires physicians to report euthanasia to a review committee. We studied which arguments Dutch physicians use to substantiate their adherence to the criteria and which aspects attract review committees' attention.

Methods

We examined 158 files of reported euthanasia and physician-assisted suicide cases that were approved by the review committees. We studied the physicians' reports and the verdicts of the review committees by using a checklist.

Results

Physicians reported that the patient's request had been well-considered because the patient was clear-headed (65%) and/or had repeated the request several times (23%). Unbearable suffering was often substantiated with physical symptoms (62%), function loss (33%), dependency (28%) or deterioration (15%). In 35%, physicians reported that there had been alternatives to relieve patients' suffering which were refused by the majority. The nature of the relationship with the consultant was sometimes unclear: the consultant was reported to have been an unknown colleague (39%), a known colleague (21%), otherwise (25%), or not clearly specified in the report (24%). Review committees relatively often scrutinized the consultation (41%) and the patient's (unbearable) suffering (32%); they had few questions about possible alternatives (1%).

Conclusion

Dutch physicians substantiate their adherence to the criteria in a variable way with an emphasis on physical symptoms. The information they provide is in most cases sufficient to enable adequate review. Review committees' control seems to focus on (unbearable) suffering and on procedural issues.

Two Decades of Research on Euthanasia from the Netherlands. What Have We Learnt and What Questions Remain?

Two decades of research on euthanasia in the Netherlands have resulted into clear insights in the frequency and characteristics of euthanasia and other medical end-of-life decisions in the Netherlands. These empirical studies have contributed to the quality of the public debate, and to the regulating and public control of euthanasia and physician-assisted suicide. No slippery slope seems to have occurred. Physicians seem to adhere to the criteria for due care in the large majority of cases. Further, it has been shown that the majority of physicians think that the euthanasia Act has improved their legal certainty and contributes to the carefulness of life-terminating acts. In 2005, eighty percent of the euthanasia cases were reported to the review committees. Thus, the transparency envisaged by the Act still does not extend to all cases. Unreported cases almost all involve the use of opioids, and are not considered to be euthanasia by physicians. More education and debate is needed to disentangle in these situations which acts should be regarded as euthanasia and which should not. Medical end-of-life decision-making is a crucial part of end-of-life care. It should therefore be given continuous attention in health care policy and medical training. Systematic periodic research is crucial for enhancing our understanding of end-of-life care in modern medicine, in which the pursuit of a good quality of dying is nowadays widely recognized as an important goal, in addition to the traditional goals such as curing diseases and prolonging life.