Euthanasia And Physician-assisted Suicide Research Articles

Physicians’ views on the role of relatives in euthanasia and physician-assisted suicide decision-making: a mixed-methods study among physicians in the Netherlands

BackgroundRelatives have no formal position in the practice of euthanasia and physician-assisted suicide (EAS) according to Dutch legislation. However, research shows that physicians often involve relatives in EAS decision-making. It remains unclear why physicians do (not) want to involve relatives. Therefore, we examined how many physicians in the Netherlands involve relatives in EAS decision-making and explored reasons for (not) involving relatives and what involvement entails.MethodsIn a mixed-methods study, 746 physicians (33% response rate) completed a questionnaire, and 20 were interviewed. The questionnaire included two statements on relatives’ involvement in EAS decision-making. Descriptive statistics were used, and multivariable logistic regression analyses to explore characteristics associated with involving relatives. In subsequent interviews, we explored physicians’ views on involving relatives in EAS decision-making. Interviews were thematically analysed.ResultsThe majority of physicians want to know relatives’ opinions about an EAS request (80%); a smaller group also takes these opinions into account in EAS decision-making (35%). Physicians who had ever received an explicit EAS request were more likely to want to know opinions and clinical specialists and elderly care physicians were more likely to take these opinions into account. In interviews, physicians mentioned several reasons for involving relatives: e.g. to give relatives space and help them in their acceptance, to tailor support, to be able to perform EAS in harmony, and to mediate in case of conflicting views. Furthermore, physicians explained that relatives’ opinions can influence the decision-making process but cannot be a decisive factor. If relatives oppose the EAS request, physicians find the process more difficult and try to mediate between patients and relatives by investigating relatives’ objections and providing appropriate information. Reasons for not taking relatives’ opinions into account include not wanting to undermine patient autonomy and protecting relatives from a potential burdensome decision.ConclusionsAlthough physicians know that relatives have no formal role, involving relatives in EAS decision-making is common practice in the Netherlands. Physicians consider this important as relatives need to continue with their lives and may need bereavement support. Additionally, physicians want to perform EAS in harmony with everyone involved. However, relatives’ opinions are not decisive.

Euthanasia and physician-assisted suicide in people with intellectual disabilities and/or autism spectrum disorders: investigation of 39 Dutch case reports (2012-2021).

Euthanasia review committees (Regionale Toetsingscommissies Euthanasie, RTE) scrutinise all Dutch cases of euthanasia and physician-assisted suicide (EAS) to review whether six legal 'due care' criteria are met, including 'unbearable suffering without prospect of improvement'. There are significant complexities and ethical dilemmas if EAS requests are made by people with intellectual disabilities or autism spectrum disorders (ASD). To describe the characteristics and circumstances of people with intellectual disabilities and/or ASD who were granted their EAS request; investigate the main causes of suffering that led to the EAS request; and examine physicians' response to the request. The online RTE database of 927 EAS case reports (2012-2021) was searched for patients with intellectual disabilities and/or ASD (n = 39). Inductive thematic content analysis was performed on these case reports, using the framework method. Factors directly associated with intellectual disability and/or ASD were the sole cause of suffering described in 21% of cases and a major contributing factor in a further 42% of cases. Reasons for the EAS request included social isolation and loneliness (77%), lack of resilience or coping strategies (56%), lack of flexibility (rigid thinking or difficulty adapting to change) (44%) and oversensitivity to stimuli (26%). In one-third of cases, physicians noted there was 'no prospect of improvement' as ASD and intellectual disability are not treatable. Examination of societal support for suffering associated with lifelong disability, and debates around the acceptability of these factors as reasons for granting EAS, are of international importance.

Perspectives of Major World Religions regarding Euthanasia and Assisted Suicide: A Comparative Analysis

Euthanasia and physician-assisted suicide (EPAS) are important contemporary societal issues and religious faiths offer valuable insights into any discussion on this topic. This paper explores perspectives on EPAS of the four major world religions, Christianity, Islam, Hinduism and Buddhism, through analysis of their primary texts. A literature search of the American Theological Library Association database revealed 41 relevant secondary texts from which pertinent primary texts were extracted and exegeted. These texts demonstrate an opposition to EPAS based on themes common to all four religions: an external locus of morality and the personal hope for a better future after death that transcends current suffering. Given that these religions play a significant role in the lives of billions of adherents worldwide, it is important that lawmakers consider these views along with conscientious objection in jurisdictions where legal EPAS occurs. This will not only allow healthcare professionals and institutions opposed to EPAS to avoid engagement, but also provide options for members of the public who prefer an EPAS-free treatment environment.

Content analysis of euthanasia polls in Australia and New Zealand: words do matter.

There has been widespread public and political interest in Euthanasia and Physician-Assisted Suicide (EPAS) in recent years. Polling in Australia and New Zealand has generally shown a majority of people support some form of legal EPAS; however, the level of support varies between polls. To explore whether public support for and opposition to EPAS as measured in historic Australian and New Zealand polls has been influenced by the wording of survey questions. Australian and New Zealand random-sample post-1995 EPAS poll questions asked of the general public were identified and subjected to content analysis. Individual phrases and words were considered in terms of their favourability towards or unfavourability against EPAS and each poll question was assigned a net favourability score. Variation of support for EPAS based on year, location and favourability of language was analysed by various statistical methods. Mean public support for EPAS in Australia and New Zealand between 1995 and the present was 70.2% with support ranging between 47 and 85%. Support did not vary by location and has remained unchanged over time. However, support was positively associated with increasing levels of favourable wording, accounting for over 20% variation in mean support. Allusions to hopelessness had an especially strong effect on increasing support for EPAS. Use of emotive phrases and language is associated with influencing attitudes to EPAS in Australia and New Zealand. Therefore, caution should be exercised when interpreting public support for EPAS based on individual polls.

Euthanasia and Physician-Assisted Suicide in Patients With Multiple Geriatric Syndromes

The Dutch Regional Euthanasia Review Committees (RTEs) reviewed and reported an increasing number of cases of euthanasia and physician-assisted suicide (EAS) requested by older people with multiple geriatric syndromes (MGS). Knowledge of the characteristics of cases of EAS for MGS is important to facilitate societal debate and to monitor EAS practice. To examine the accumulation of patient characteristics, geriatric syndromes, and other circumstances as reported in the case summaries of the RTEs that led to unbearable suffering associated with a request for EAS and to analyze the RTEs' assessments of these cases of EAS. A qualitative content analysis was conducted of all case summaries filed from January 1, 2013, to December 31, 2019, under the category MGS and published in a national open access database. These case summaries were selected by the RTEs from the total of 1605 reported cases of EAS in the category MGS. The RTEs published 53 cases (41 [77%] female) under the category MGS. A total of 28 patients (53%) had always perceived themselves as independent, active, and socially involved. None of the patients suffered from life-threatening conditions. Multiple geriatric syndromes, such as visual impairment (34 cases [64%]), hearing loss (28 cases [53%]), pain (25 cases [47%]), and chronic tiredness (22 cases [42%]), were common. The request for EAS was often preceded by a sequence of events, especially recurrent falls (33 cases [62%]). Although physical suffering could be determined in all cases, the case descriptions found that suffering occurred on multiple dimensions, such as the loss of mobility (44 [83%]), fears (21 [40%]), dependence (23 [43%]), and social isolation (19 [36%]). This qualitative study suggests that an accumulation of geriatric syndromes leading to a request for EAS is often intertwined with the social and existential dimension of suffering. This leads to a complex interplay of physical, psychological, and existential suffering that changes over time.

Euthanasia and assisted suicide in patients with personality disorders: a review of current practice and challenges

BackgroundOver the last two decades an increasing number of countries have legalized euthanasia and physician-assisted suicide (EAS) leading to considerable debate over the inherent ethical dilemmas. Increasing numbers of people with personality disorders, faced with unbearable suffering, have requested and received assistance in terminating their lives. EAS in people with personality disorders has, however, received very sparse attention from clinicians and researchers. In this paper, we examine the literature on the practice and prevalence of EAS in people with personality disorders to date and discuss the associated challenges for research and practice.MethodsNarrative review of the literature combined with the authors’ collective experience and knowledge of personality disorders.ResultsIn six of the eight countries where EAS is currently legal, mental disorders are accepted as disorders for which EAS may be granted. In four of these countries, EAS in minors with mental disorders is also accepted. Our literature search resulted in 9 papers on the subject of EAS in people with personality disorders. These studies suggest that most clinicians who grant EAS have indeed perceived their patients’ suffering as chronic, unbearable and untreatable without prospect of improvement. The majority of patients with personality disorders had tried some form of psychotherapy, but very few had received any of the relevant evidence-based treatments. The decision to grant EAS based on a perception of the patient’s illness as being untreatable with no prospect of improvement, could, thus, in many cases fail to meet the due care criteria listed in EAS laws. People with personality disorders more often wish for death for extended periods of time than people without these disorders. However, there is ample empirical data to show that suicidal tendencies and behaviour can be treated and that they fluctuate rapidly over time.ConclusionsIn light of our findings, we believe that the current legislation and practice of EAS for people with personality disorders is based on an inadequate understanding of underlying psychopathology and a lack of awareness about the contemporary treatment literature. Moreover, we assert that this practice neglects the individual’s potential for having a life worth living.

Considerations by Dutch Psychiatrists Regarding Euthanasia and Physician-Assisted Suicide in Psychiatry: A Qualitative Study.

Euthanasia and physician-assisted suicide (EAS) in psychiatry are permitted in the Netherlands under certain legal conditions. Doctors may help patients who suffer unbearably and who have no prospect of improvement from psychiatric illnesses. Although this practice is permitted, it remains controversial, and the acceptability of EAS and the conditions under which it should be allowed are still debated. As the number of psychiatric patients requesting EAS is increasing, Dutch psychiatrists are becoming more reluctant to consider EAS. This study aims for a better understanding of Dutch psychiatrists' considerations for supporting or rejecting EAS for psychiatric patients. The data for this qualitative study were collected through 17 in-depth interviews with Dutch psychiatrists. These interviews were held from January until June 2016 as a part of the Third Evaluation of the Dutch Termination of Life on Request and Assisted Suicide Act. Irrespective of their own position in the debate, most Dutch psychiatrists consider reasons for and against EAS, including moral (justice and equality, professional responsibility, compassion), epistemologic (how can one ever know the suffering is without prospect), practical, and contextual (mental health care provisions) reasons. The variation in views on EAS in psychiatry seems to be related to a difference in views on the nature of psychiatric diseases. Some psychiatrists stress the similarity between psychiatric and somatic diseases, whereas others stress the fundamental difference. These opposing views could be bridged by a pragmatic view, such as a 2-track approach to EAS.

Commonalities and differences in legal euthanasia and physician-assisted suicide in three countries: a population-level comparison.

To describe and compare euthanasia and physician-assisted suicide (EAS) practice in Flanders, Belgium (BE), the Netherlands (NL) and Switzerland (CH). Mortality follow-back surveys among attending physicians of a random sample of death certificates. We studied 349 EAS deaths in BE (4.6% of all deaths), 851 in NL (4.6% of all deaths) and 65 in CH (1.4% of all deaths). People who died by EAS were mostly aged 65 or older (BE: 81%, NL: 77% and CH: 71%) and were mostly diagnosed with cancer (BE: 57% and NL: 66%). Home was the most common place of death in NL (79%), while in BE and CH, more variation was found regarding to place of death. The decision to perform EAS was more frequently discussed with a colleague physician in BE (93%) and NL (90%) than in CH (60%). EAS practice characteristics vary considerably in the studied countries with legal EAS. In addition to the legal context, cultural factors as well as the manner in which legislation is implemented play a role in how EAS legislation translates into practice.

The involvement of family in the Dutch practice of euthanasia and physician assisted suicide: a systematic mixed studies review

BackgroundFamily members do not have an official position in the practice of euthanasia and physician assisted suicide (EAS) in the Netherlands according to statutory regulations and related guidelines. However, recent empirical findings on the influence of family members on EAS decision-making raise practical and ethical questions. Therefore, the aim of this review is to explore how family members are involved in the Dutch practice of EAS according to empirical research, and to map out themes that could serve as a starting point for further empirical and ethical inquiry.MethodsA systematic mixed studies review was performed. The databases Pubmed, Embase, PsycInfo, and Emcare were searched to identify empirical studies describing any aspect of the involvement of family members before, during and after EAS in the Netherlands from 1980 till 2018. Thematic analysis was chosen as method to synthesize the quantitative and qualitative studies.ResultsSixty-six studies were identified. Only 14 studies had family members themselves as study participants. Four themes emerged from the thematic analysis. 1) Family-related reasons (not) to request EAS. 2) Roles and responsibilities of family members during EAS decision-making and performance. 3) Families’ experiences and grief after EAS. 4) Family and ‘the good euthanasia death’ according to Dutch physicians.ConclusionFamily members seem to be active participants in EAS decision-making, which goes hand in hand with ambivalent feelings and experiences. Considerations about family members and the social context appear to be very important for patients and physicians when they request or grant a request for EAS. Although further empirical research is needed to assess the depth and generalizability of the results, this review provides a new perspective on EAS decision-making and challenges the Dutch ethical-legal framework of EAS. Euthanasia decision-making is typically framed in the patient-physician dyad, while a patient-physician-family triad seems more appropriate to describe what happens in clinical practice. This perspective raises questions about the interpretation of autonomy, the origins of suffering underlying requests for EAS, and the responsibilities of physicians during EAS decision-making.

Euthanasia and physician-assisted suicide in patients suffering from psychiatric disorders: a cross-sectional study exploring the experiences of Dutch psychiatrists

BackgroundThe medical-ethical dilemmas related to euthanasia and physician-assisted suicide (EAS) in psychiatric patients are highly relevant in an international context. EAS in psychiatric patients appears to become more frequent in the Netherlands. However, little is known about the experiences of psychiatrists with this practice. This study aims to estimate the incidence of EAS (requests) in psychiatric practice in The Netherlands and to describe the characteristics of psychiatric patients requesting EAS, the decision-making process and outcomes of these requests.MethodsIn the context of the third evaluation of the Dutch Euthanasia Act, a cross-sectional study was performed between May and September 2016. A questionnaire was sent to a random sample of 500 Dutch psychiatrists. Of the 425 eligible psychiatrists 49% responded. Frequencies of EAS and EAS requests were estimated. Detailed information was asked about the most recent case in which psychiatrists granted and/or refused an EAS request, if any.ResultsThe total number of psychiatric patients explicitly requesting for EAS was estimated to be between 1100 and 1150 for all psychiatrists in a one year period from 2015 to 2016. An estimated 60 to 70 patients received EAS in this period. Nine psychiatrists described a case in which they granted an EAS request from a psychiatric patient. Five of these nine patients had a mood disorder. Three patients had somatic comorbidity. Main reasons to request EAS were ‘depressive feelings’ and ‘suffering without prospect of improvement’. Sixty-six psychiatrists described a case in which they refused an EAS request. 59% of these patients had a personality disorder and 19% had somatic comorbidity. Main reasons to request EAS were ‘depressive feelings’ and ‘desperate situations in several areas of life’. Most requests were refused because the due care criteria were not met.ConclusionsAlthough the incidence of EAS in psychiatric patients increased over the past two decades, this practice remains relatively rare. This is probably due to the complexity of assessing the due care criteria in case of psychiatric suffering. Training and support may enable psychiatrists to address this sensitive issue in their work better.

Argumenty w sporze o legalizację eutanazji i wspomaganego samobójstwa. Część I

Celem artykulu jest prezentacja argumentow uzywanych w debacie nad legalizacją eutanazji i wspomaganego samobojstwa. Przeciwnicy legalizacji wyzej wymienionych procedur poslugują sie argumentem moralnym ze świetości zycia oraz argumentem poza moralnym z rowni pochylej. Zalozeniem argumentu świetości zycia jest niemoralnośc wszelkich form zabijania terminalna choroba i związane z nią cierpienie nie są okolicznościami usprawiedliwiającymi przerwanie zycia. Ochrona zycia stanowi fundament funkcjonowania spoleczenstwa. Argument rowni pochylej opiera sie na nastepującym zalozeniu: jeśli uczyniony zostanie wyjątek od zasady nienaruszalności zycia w postaci np. eutanazji lub wspomaganego samobojstwa osob terminalnie chorych, ktore są pelnoletnie i wyrazają wolną od naciskow prośbe, w konsekwencji doprowadzi to do zabijania osob chorych, starych czy kalekich bez ich zgody lub nawet wbrew ich woli. Chodzi tu o zmiany w świadomości spolecznej, ktore mogą doprowadzic do zakwestionowania wartości zycia ludzkiego. Mozliwe jest takze wystąpienie trudnych do kontrolowania naduzyc. Zwolennicy przyspieszania śmierci formulują dwa argumenty moralne: argument z autonomii jednostki i argument z jakości zycia. Argument z autonomii jednostki jest przedstawiany jako wyraz szacunku do czlowieka i dokonywanych przez niego wyborow. Kazdy ma prawo zdecydowac kiedy wlasne zycie przestaje byc dla niego wartością, w szczegolności zaś w przypadku choroby i cierpienia, a zatem wybrac tzw. godną śmierc bez cierpienia i zalezności od innych. Zwolennicy tego argumentu stwierdzają, ze zasada autonomii moze byc rownie wazna lub nawet wazniejsza od zasady nienaruszalności zycia, jednocześnie jest ona odpowiedzią na paternalizm medyczny. Wlaśnie tego argumentu uzyto w panstwach, ktore zalegalizowaly eutanazje i wspomagane samobojstwo (panstwach Beneluksu, Kanadzie oraz w nastepujących stanach w USA: Oregonie, Waszyngtonie, Montanie, Vermoncie, Kalifornii, Dystrykcie Kolumbii oraz Kolorado). Kolejny argument zwolennikow dopuszczalności eutanazji i wspomaganego samobojstwa to argument moralny z jakości zycia, zaklada on, ze w pewnych okolicznościach zycie i jego kontynuacja nie stanowią dobra dla osoby. Argument z jakości zycia polega na oszacowaniu czy zycie ma dla chorego wartośc, czy tez pozostaje tylko ciezarem lub ogranicza sie do biologicznego trwania, jak np. w przypadku osob w przetrwalym stanie wegetatywnym. Nalezy zaznaczyc, ze to jaka zostanie uzyta argumentacja bedzie mialo wplyw na ksztalt przyszlych rozwiązan prawnych związanych z medycznie wspomaganą śmiercią.

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...

Developments in the practice of physician-assisted dying: perceptions of physicians who had experience with complex cases

BackgroundSince the enactment of the euthanasia law in the Netherlands, there has been a lively public debate on assisted dying that may influence the way patients talk about euthanasia and...

Physician-assisted suicide and/or euthanasia: Pragmatic implications for palliative care [corrected

Despite the availability of palliative care in many countries, legalization of euthanasia and physician-assisted suicide (EAS) continues to be debated-particularly around ethical and legal issues--and the surrounding controversy shows no signs of abating. Responding to EAS requests is considered one of the most difficult healthcare responsibilities. In the present paper, we highlight some of the less frequently discussed practical implications for palliative care provision if EAS were to be legalized. Our aim was not to take an explicit anti-EAS stance or expand on findings from systematic reviews or philosophical and ethico-legal treatises, but rather to offer clinical perspectives and the potential pragmatic implications of legalized EAS for palliative care provision, patients and families, healthcare professionals, and the broader community. We provide insights from our multidisciplinary clinical experience, coupled with those from various jurisdictions where EAS is, or has been, legalized. We believe that these issues, many of which are encountered at the bedside, must be considered in detail so that the pragmatic implications of EAS can be comprehensively considered. Increased resources and effort must be directed toward training, research, community engagement, and ensuring adequate resourcing for palliative care before further consideration is given to allocating resources for legalizing euthanasia and physician-assisted suicide.

Complexities in Euthanasia or Physician-Assisted Suicide as Perceived by Dutch Physicians and Patients' Relatives

ContextThe practice of euthanasia and physician-assisted suicide (EAS) is always complex, but some cases are more complex than others. The nature of these unusually complex cases is not known. ObjectivesTo identify and categorize the characteristics of EAS requests that are more complex than others. MethodsWe held in-depth interviews with 28 Dutch physicians about their perception of complex cases of EAS requests. We also interviewed 26 relatives of patients who had died by EAS. We used open coding and inductive analysis to identify various different aspects of the complexities described by the participants. ResultsComplexities can be categorized into relational difficulties—such as miscommunication, invisible suffering, and the absence of a process of growth toward EAS—and complexities that arise from unexpected situations, such as the capricious progress of a disease or the obligation to move the patient. The interviews showed that relatives of the patient influence the process toward EAS. ConclusionFirst, the process toward EAS may be disrupted, causing a complex situation. Second, the course of the process toward EAS is influenced not only by the patient and his/her attending physician but also by the relatives who are involved. Communicating and clarifying expectations throughout the process may help to prevent the occurrence of unusually complex situations.

Suffering in the Context of Euthanasia and Assisted Suicide: Transcending Job through Wojtyla's Anthropology

The debate over euthanasia and physician-assisted suicide (EPAS) continues to ignore the philosophical anthropology on which certain critical claims rest. In this paper, I offer several anthropologically based arguments against one prominent justification for EPAS: the Argument from the Evil of Suffering. I demonstrate that the argument is, at its core, a utilitarian one, and that a sound rebuttal can be found by examining Karol Wojtyla/Pope John Paul II's view of suffering as a transformative experience for the human person. Wojtyla both rejects the secular bioethics vision of meaningless, quantifiable suffering, but also offers to take Christian bioethics far beyond the story of Job and into the realm of phenomenological change. By focusing on participation of the suffering sick in community with others, and rejecting alienation, Christians can arrive at a more complete conception of suffering that embraces the complementarities of philosophy and theology.

Development and dissemination of institutional practice guidelines on medical end-of-life decisions in Dutch health care institutions

To describe how Dutch healthcare institutions develop and disseminate institutional practice guidelines on medical end-of-life decisions and policy statements on euthanasia and physician-assisted suicide (EAS) to relevant parties, and to describe supportiveness of EAS guidelines experienced by Dutch physicians. Questionnaires to all Dutch health care institutions in 2005. Questionnaire to sample of Dutch clinical specialists and nursing home physicians. In most health care institutions, physicians (79%), ethics committees (79%), board of directors (64%) and nurses (61%) were involved in the development of guidelines. The Euthanasia Act and national guidelines were the most frequently reported sources for the development (73% and 71%, respectively). Not all institutions disseminated their written EAS policy statements and practice guidelines on medical end-of-life decisions to all relevant parties. Dutch physicians who reported the presence of a written guideline for EAS in their institution, felt supported by it in their decision-making after a patient's request for EAS. It is recommended that more health care institutions pay attention to the dissemination of their policy statements and practice guidelines to relevant parties. This will only lead to improvement in medical practice if this is accompanied by efforts to also stimulate the use of guidelines in practice.

Policy statements and practice guidelines for medical end-of-life decisions in Dutch health care institutions: Developments in the past decade

To describe the existence of policy statements on euthanasia and physician-assisted suicide (EAS) and practice guidelines for all medical end-of-life decisions in Dutch health care institutions in 2005, whether the existence of practice guidelines is related to characteristics of institutions, and to compare the existence of policies in 2005 and 1994. Questionnaires were sent to 566 institutions (all Dutch hospitals, nursing homes, general psychiatric hospitals, institutions for the mentally disabled, hospices) from October 2005 through March 2006. Most institutions (70%) had a written policy statement concerning EAS. EAS was usually allowed under specific conditions (75%). Institutions mainly had practice guidelines for EAS and do-not-resuscitate decisions (62% and 63%). A minority had guidelines on palliative sedation (27%), alleviation of symptoms (27%) and withdrawing or withholding treatment (33%). In general, there were more practice guidelines in 2005 than in 1994. Larger institutions and institutions with an ethics committee more often had practice guidelines. Religious affiliation of an institution did not seem to be related to the existence of guidelines. Since many institutions still do not have practice guidelines for medical end-of-life decisions, they should be stimulated to introduce practice guidelines, being a first step in improving the quality of the care on institutional level.

Granted, Undecided, Withdrawn, and Refused Requests for Euthanasia and Physician-Assisted Suicide

The aims of this study were to obtain information about the characteristics of requests for euthanasia and physician-assisted suicide (EAS) and to distinguish among different types of situations that can arise between the request and the physician's decision. All general practitioners in 18 of the 23 Dutch general practitioner districts received a written questionnaire in which they were asked to describe the most recent request for EAS they received. A total of 3614 general practitioners responded to the questionnaire (response rate, 60%). Of all explicit requests for EAS, 44% resulted in EAS. In the other cases the patient died before the performance (13%) or finalization of the decision making (13%), the patient withdrew the request (13%), or the physician refused the request (12%). Patients' most prominent symptoms were "feeling bad," "tiredness," and "lack of appetite." The most frequently mentioned reasons for requesting EAS were "pointless suffering," "loss of dignity," and "weakness." The patients' situation met the official requirements for accepted practice best in requests that resulted in EAS and least in refused requests. A lesser degree of competence and less unbearable and hopeless suffering had the strongest associations with the refusal of a request. The complexity of EAS decision making is reflected in the fact that besides granting and refusing a request, 3 other situations could be distinguished. The decisions physicians make, the reasons they have for their decisions, and the way they arrived at their decisions seem to be based on patient evaluations. Physicians report compliance with the official requirements for accepted practice.

Requests for euthanasia or physician-assisted suicide from older persons who do not have a severe disease: an interview study

To determine how often requests are made for euthanasia and physician-assisted suicide (EAS) in the absence of severe disease and how such requests are dealt with in medical practice in The Netherlands. Retrospective interview study. 125 general practitioners (GPs), 77 nursing home physicians (NHPs), and 208 clinical specialists. In The Netherlands, each year approximately 400 people request EAS, because they are 'weary of life'. Thirty per cent of all physicians have at some time received an explicit request for EAS in the absence of severe disease; 3% of all physicians had granted a request for EAS in such a case. Most requests for EAS to GPs in the absence of severe disease (n = 29) were made by single people aged 80 years and over. While their problems were most frequently of a social nature, 79% had one or more non-severe illnesses. Most GPs refused the request; half of them proposed an alternative treatment, which the patient often refused. Nineteen people who did not receive any treatment persisted in their wish to die; the request for EAS from 5 out of 10 patients who received one or more types of treatment was withdrawn or became less explicit. Most physicians in The Netherlands refuse requests for EAS in the absence of severe disease. Most patients persist in their request. In an ageing population more research is needed to provide physicians with practical interventions to prevent suicide and to make life bearable and satisfactory for elderly people who wish to die.