Euthanasia In The Netherlands Research Articles

Nursing staff and euthanasia in the Netherlands. A nation-wide survey on attitudes and involvement in decision making and the performance of euthanasia

ObjectivesTo give insight into Dutch nursing staff’s attitudes and involvement regarding euthanasia. MethodsThe sample was recruited from a nation-wide existent research panel of registered nurses and certified nursing assistants. Descriptive analyses and multivariate logistic regression analyses were performed. Results587 respondents (response of 65%) completed the questionnaire. The majority (83%) state that physicians have to discuss the decision about euthanasia with the nurses involved. Besides, 69% state that a physician should discuss a euthanasia request with nurses who have regular contact with a patient. Nursing staff who have religious or other beliefs that they consider important for their attitude towards end-of-life decisions, and staff working in a hospital or home care, are most likely to have this opinion. Being present during the euthanasia is quite unusual: only a small group (7%) report that this has ever been the case in their entire working life. Seven% (incorrectly) think they are allowed to administer the lethal drugs. ConclusionThe majority want to be involved in decision-making processes about euthanasia. Not all are aware that they are not legally allowed to administer the lethal drugs. Practice implicationsNursing staff should be informed of relevant existing legislation and professional guidelines.

IS6.08: Euthanasia in the Netherlands: medical practice and societal control

IS6.08: Euthanasia in the Netherlands: medical practice and societal control

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?

BackgroundIn 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. ObjectiveTo 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. MethodsDuring 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. ResultsWe 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. ConclusionPsychological 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.

Euthanasia in the Netherlands: Consultation and Review

The Netherlands was the first country in which euthanasia (defined as the active termination of life by a physician at the request of the patient) and physician-assisted suicide (PAS) were legally permitted under specific circumstances. Much controversy exists regarding the moral legitimacy of assistance in dying, if this involves actively and deliberately shortening the life of the patient. This is particularly the case if patients do not (or do not only) suffer from somatic illnesses, but instead (or also) suffer from mental disturbance, such as in the case of chronic mental illness or Alzheimer's disease.

Euthanasia in the Netherlands: what lessons for elsewhere?

Euthanasia in the Netherlands: what lessons for elsewhere?

Empathy and the application of the ‘unbearable suffering’ criterion in Dutch euthanasia practice

A pivotal due care criterion for lawful euthanasia in the Netherlands is that doctors must be convinced that a patient requesting for euthanasia, suffers unbearably. Our study aims to find out how doctors judge if a patient suffers unbearably. How do doctors bridge the gap from 3rd person assessment to 1st person experience? We performed a qualitative interview study among 15 physicians, mainly general practitioners, who participated earlier in a related quantitative survey on the way doctors apply the suffering criterion. Results show that doctors follow different ‘cognitive routes’ when assessing a patients suffering in the context of a euthanasia request. Sometimes doctors do this imagining how she herself would experience the situation of the patient (‘imagine self’). Doctors may also try to adopt the perspective of the patient and imagine what the situation is like for this particular patient (‘imagine other’). Besides this we found that the (outcome of the) assessment is influenced by a doctor's private norms, values and emotions considering (the performance of) euthanasia. We conclude by arguing why doctors should be aware of both the ‘cognitive route’ followed as well as the influence of their own personal norms on the assessment of suffering in the context of euthanasia requests.

Judgment of unbearable suffering and willingness to grant a euthanasia request by Dutch general practitioners

'Unbearable suffering' is a pivotal criterion for lawful euthanasia in the Netherlands. The due-care criterion is not defined in the law and could refer to conditions varying from physical pain to psychological forms of suffering. It is unknown, however, what doctors consider 'unbearable suffering' and for what kind of suffering they are willing to grant a euthanasia request. We conducted a vignette-study among Dutch general practitioners (n=115, response 38%). We found high concordance between the classification of a patient's suffering as 'unbearable' and the willingness to grant a euthanasia request. Most doctors are only inclined to classify a patient's suffering as 'unbearable' when suffering is directly related to untreatable and actual pain or physical symptoms. Doctors' judgment of suffering varied strongly in cases in which physical symptoms are absent and a patient suffers from a combination of irreversible functional loss and 'existential' kinds of suffering. Although some doctors (17%) stick to the idea that physical symptoms are a necessary condition for 'unbearable suffering', a majority is willing to occasionally make an exception. When and for which case an individual doctor will make such an exception, is highly unpredictable. Various explanations for the findings are discussed.

Requests for euthanasia: origin of suffering in ALS, heart failure, and cancer patients

In The Netherlands, relatively more patients (20%) with amyotrophic lateral sclerosis (ALS) die due to euthanasia or physician-assisted suicide (EAS) compared with patients with cancer (5%) or heart failure (0.5%). We wanted to gain insight into the reasons for ALS patients requesting EAS and compare these with the reasons of cancer and heart failure patients. Knowing disease-specific reasons for requesting EAS may improve palliative care in these vulnerable patients. The data used in the present study were derived from the Support and Consultation in Euthanasia in The Netherlands (SCEN) evaluation study. This study provided consultation reports and questionnaires filled out by the attending physicians from 3,337 consultations conducted by SCEN physicians in situations where a patient requested EAS. For this study we selected data on all ALS patients (n = 51), all heart failure patients (n = 61), and a random sample of 73 cancer patients. The most frequently reported reasons for unbearable suffering were: fear of suffocation (45%) and dependency (29%) in ALS patients, pain (46%) and fatigue (28%) in cancer patients, and dyspnea (52%) and dependency (37%) in heart failure patients. Somatic complaints were reported more frequently as a reason for EAS by cancer patients [odds ratio (OR) 0.20, 95% confidence interval (CI) 0.09-0.46] and heart failure patients [OR 0.16, 95% CI 0.05-0.46] than by ALS patients. ALS patients should be helped in a timely fashion to cope with psychosocial symptoms, e.g., by informing them about the low risk of suffocation in the terminal phase and the possible means of preventing this.

ADVANCE DIRECTIVES IN THE NETHERLANDS: AN EMPIRICAL CONTRIBUTION TO THE EXPLORATION OF A CROSS‐CULTURAL PERSPECTIVE ON ADVANCE DIRECTIVES

This study focuses on ADs in the Netherlands and introduces a cross-cultural perspective by comparing it with other countries. A questionnaire was sent to a panel comprising 1621 people representative of the Dutch population. The response was 86%. 95% of the respondents didn't have an AD, and 24% of these were not familiar with the idea of drawing up an AD. Most of those familiar with ADs knew about the Advanced Euthanasia Directive (AED, 64%). Both low education and the presence of a religious conviction that plays an important role in one's life increase the chance of not wanting to draw up an AD. Also not having experienced a request for euthanasia from someone else, and the inconceivability of asking for euthanasia yourself, increase the chance of not wanting to draw up an AD. This study shows that the subjects of palliative care and end-of-life-decision-making were very much dominated by the issue of euthanasia in the Netherlands. The AED was the best known AD; and factors that can be linked to euthanasia play an important role in whether or not people choose to draw up an AD. This differentiates the Netherlands from other countries and, when it comes to ADs, the global differences between countries and cultures are still so large that the highest possible goals, at this moment in time, are observing and possibly learning from other cultural settings.

Establishing specialized health services for professional consultation in euthanasia: experiences in the Netherlands and Belgium

BackgroundThe Netherlands, Belgium, and Luxembourg have adopted laws decriminalizing euthanasia under strict conditions of prudent practice. These laws stipulate, among other things, that the attending physician should consult an independent colleague to judge whether the substantive criteria of due care have been met. In this context initiatives were taken in the Netherlands and Belgium to establish specialized services providing such consultants: Support and Consultation for Euthanasia in the Netherlands (SCEN) and Life End Information Forum (LEIF) in Belgium. The aim of this study is to describe and compare these initiatives.MethodsWe studied and compared relevant documents concerning the Dutch and Belgian consultation service (e.g. articles of bye-laws, inventories of activities, training books, consultation protocols).ResultsIn both countries, the consultation services are delivered by trained physicians who can be consulted in cases of a request for euthanasia and who offer support and information to attending physicians. The context in which the two organisations were founded, as well as the way they are organised and regulated, is different in each country. By providing information on all end-of-life care matters, the Belgian LEIF seems to have a broader consultation role than the Dutch SCEN. SCEN on the other hand has a longer history, is more regulated and organised on a larger scale and receives more government funding than LEIF. The number of training hours for physicians is equal. However, SCEN-training puts more emphasis on the consultation report, whereas LEIF-training primarily emphasizes the ethical framework of end-of-life decisions.ConclusionIn case of a request for euthanasia, in the Netherlands as well as in Belgium similar consultation services by independent qualified physicians have been developed. In countries where legalising physician-assisted death is being contemplated, the development of such a consultation provision could also be considered in order to safeguard the practice of euthanasia (as it can provide safeguards to adequate performance of euthanasia and assisted suicide).

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.

Is euthanasie een maakbare dood? Een bijdrage vanuit het perspectief van de meldingsprocedure Dominion Over Death? Euthanasia from the Perspective of the Review Procedure

Euthanasia can be viewed as a necessary response to extreme terminal suffering, but also as a brave expression of humans taking their destiny in their own hands. Reports sent to euthanasia review committees often motivate a patient’s choice for euthanasia in terms of an autonomous choice. On the basis of an analysis of 1,000 euthanasia cases from the review procedure in the years 2005-2008, it is argued that euthanasia in the Netherlands is predominantly an emergency reaction rather than an expression of autonomy. From a closer look at the data we learn that the autonomy card is only played in the context of extreme suffering without any prospect of improvement.

How do general practitioners assess the criteria for due care for euthanasia in concrete cases?

In the Netherlands the law states that physicians are allowed to grant a request for euthanasia or physician-assisted suicide (EAS) if specific criteria for due care are met. This study investigated which sources physicians use to determine whether three of these criteria (unbearable and hopeless suffering, and no realistic alternatives for treatment) are met. The data were collected for the project Support and Consultation on Euthanasia in the Netherlands. General practitioners (GPs) received a written questionnaire concerning the most recent request for EAS that they had received. Of the 3614 (60%) GPs who returned the questionnaire, 1681 described the most recent request for EAS. The study shows that physicians used different types of sources, and more than one source, to determine whether the criteria were met. More sources were used when the criteria were met or when a request resulted in EAS. The determination of every criterion required a different approach, but for all criteria discussions with colleagues were important. Using less sources when a criterion is not met could possibly lead to less extensive consideration of the criteria, and therefore to assessing too easily that the request does not meet the criteria for due care.

Organized Obfuscation: Advocacy for Physician-Assisted Suicide

An ancient but evergreen practice with controversial political and ethical issues is to manipulate ideas and language, spinning them to serve one's ends. My example will be the current physician-assisted suicide debate, now being played out with ballot initiative in the state of Washington. The advocates for physician-assisted suicide make use of favorite method from the spin tool box, that of obfuscation, defined in dictionaries as an effort to render something unclear, evasive, or confusing. I believe that in re-Daniel Callahan, Organized Obfuscation: Advocacy for Physician-Assisted Suicide, Hastings Center Report 38, no. 5 (2008): 30-32. cent years, many (though hardly all) advocates of euthanasia and physician-assisted suicide have used organized obfuscation as political tactic, and Washington is no exception. The seeds of this interpretation were planted in my mind in the late 1980s. In the January-February 1989 issue of the Hastings Center Report we published an article by Dutch cardiologist, Richard Fenigsen, titled Case against Dutch (1) We did so with considerable trepidation. The article seemed extreme in its accusations, the only available footnotes were in Dutch, and we had no good way of independently verifying his critique. In brief, he charged that there were far more instances of euthanasia than reported, that regulations promulgated by Dutch courts to control the practice were widely ignored, and that euthanasia without informed consent of patients (called euthanasia) was common. We decided to take chance and published the article. We were almost instantly assaulted with remarkable (and obviously orchestrated) deluge of complaints from Dutch health authorities and organizations, as well as euthanasia advocacy groups. They included, among others, the Dutch Society of Health Law, twenty-five prominent medical and health care figures who joined to send us letter, and the Dutch Society for Voluntary Euthanasia. (2) Their message was uniform and unsparing: we should not have published such an irresponsible article, filled with unverifiable charges and baseless accusations and displaying gross misunderstanding of the practice of euthanasia in the Netherlands. (We Americans just didn't get it!) A few lines from those letters became memorable. One of them was that the Dutch meaning of euthanasia was that of a deliberate life-ending action ... [as the result of ] an enduring [patient] request. 'Euthanasia,' therefore, is by necessity, voluntary. (3) Another letter asserted that is impossible for people who do not want euthanasia to be forced or maneuvered into it because that would violate the definition of euthanasia. (4) The notion that one could not be forced into something because it would violate definition is surely imaginative (and philosophers of language should take note). The letters evaded the question of whether nonvoluntary euthanasia (now turned into an oxymoron) actually took place. As it turned out, however, Fenigsen was shortly proved strikingly right, even if not in all details. In series of confidential interviews with physicians and an examination of death certificates, three surveys in 1990, 1995, and 2001 found that approximately two percent of all Dutch deaths (3,500 or so) came from euthanasia and physician-assisted suicide, about 1,000 of which were without the patient's explicit request. (5) Fewer than 45 percent were reported, as required by law. But the apologists were not giving up on spin. Yes, those figures are probably correct, they seemed to say, but they did not mean what they seemed (to outsiders) to mean. Foreigners just don't understand that the Dutch doctor-patient relationship is far more intimate than in other countries. Their doctors know what their patients would want even if they have never said anything; and, besides, it is physician's ethical duty to judge the patient's quality of life and to act accordingly, even without consent. …

A lei relativa ao término da vida sob solicitação e suicídio assistido e a Constituição holandesa

The article verifies how far the legalization of euthanasia in the Netherlands is compatible with the fundamental rights recognized by the Constitution of that country. With the adoption of the Termination of Life on Request and Assisted Suicide Act, the last life protection strongholds may have begun to fall. Not only the case law of the Dutch Supreme Court is analyzed, but also the opinion of the Council of Chronically Sick and Disabled Persons of the Netherlands.

Deliberate termination of life of newborns with spina bifida

I have been following the discussion on euthanasia in The Netherlands for some time and particularly so the last years when Verhagen et al. have published some articles about euthanasia on infants (http://www.europeanhospital.com, volume 14, issue 1/05) [1–3]. These articles on the ‘Groningen Protocol’ give rise to much concern because it appears that all the euthanized children had just a single birth defect: spina bifida complicated with hydrocephalus. Having read the text of the invited article of de Jong, I would like to contribute and highlight some general principles about this kind of decision-making and also clarify profound misunderstandings about what it means to live a life with spina bifida. It seems that about once in a few decades someone publishes a set of criteria that identify infants with congenital malformations that are better off dead. It is “in their best interest” that their lives are ended. Obviously, the infant has no say in this decision. In the Groningen protocol, the infant receives a lethal injection to end life. While this may seem more humane than Lorber’s protocol about selection for nontreatment and consequently sedating and starving the infant too death, the result is the same. Unfortunately, the design and execution is carried out by a physician. There are many problems with this protocol beyond violating the rights of an individual. This issue of “quality of life” is an important one. When this phrase appears in any decision process, especially if it involves limiting the rights of another, one should pause. Like Verhagen et al., Mr. Lorber devised a set of criteria that would predict the “quality of life” of infants born with spina bifida. Several studies clearly showed these criteria to be invalid. The only thing they predicted was who was going to starve to death. Unfortunately, many infants died before most centers rejected these criteria. For 35 years I have practiced pediatric neurosurgery at Children’s Memorial in Chicago, a large urban hospital. I have participated in the care of almost 500 infants born with spina bifida. At the present time, we are following-up 1,500 children and young adults with spina bifida. This experience has taught me that any attempt to predict the outcome for an individual infant is not only unwise but also often wrong. I have also learned that we professionals, especially physicians, are often poor judges of what represents a life of “quality”. We are part of the upper economic strata of society and live lives of intellect and comfort. What we perceive as poor quality may be very acceptable to others. Commonly, those promoting these protocols are obstetricians, intensive care doctors, or others with little knowledge of what life is like for individuals with spina bifida as adults [4]. Today, nearly 90% will survive into adulthood, most will graduate high school and many will attend college. Between 70% and 75% are likely to live independently. The remaining 25% to 30% will require some assistance but will live with dignity. Over the years, I have been asked to assist families that are faced with making a difficult decision about the initial treatment of their newborn with spina bifida. Often, the parents have already spoken with a physician less involved and less experienced in the care for babies and adults with spina bifida and often have been presented a too grim Childs Nerv Syst (2008) 24:33–34 DOI 10.1007/s00381-007-0490-7

Nothing More To Do: Euthanasia, General Practice, and End-of-Life Discourse in the Netherlands

Euthanasia in the Netherlands, which has been legal since 1984, is often talked about; yet, only rarely does it culminate in a euthanasia death. In 2001, for example, only 1 in 10 of those who initiated a request for euthanasia with their physician died a euthanasia death. Using data gathered during a 15-month ethnographic study with general practitioners, families, and patients, this article explores the practice of euthanasia, a practice based mainly in talk. Applying a Foucauldian concept of discourse, I will examine euthanasia as a script for how people think, feel, and act at the end of Dutch life, attempting to answer the question: What are Dutch people talking about when they talk about euthanasia? This article is intended to provide ethnographic data not currently available on the modern-day practice of euthanasia and to add to a growing body of literature on death, dying, and the role of the state.

Relieving suffering at the end of life: Practitioners’ perspectives on palliative sedation from three European countries

This paper reports findings from visits to palliative care settings and research units in the UK, Belgium and the Netherlands. The aim was to learn about clinicians’ (both nurses and doctors) and academic researchers’ understandings and experiences of palliative sedation for managing suffering at the end of life, and their views regarding its clinical, ethical and social implications. The project was linked to two larger studies of technologies used in palliative care. Eleven doctors, 14 nurses and 10 researchers took part in informal interviews. Relevant reports and papers from the academic, clinical and popular press were also collected from the three countries. The study took place in a context in which attention has been drawn towards palliative sedation by the legalisation of euthanasia in the Netherlands and Belgium, and by the re-examination of the legal position on assisted dying in the UK. In this context, palliative sedation has been posited by some as an alternative path of action. We report respondents’ views under four headings: understanding and responding to suffering; the relationship between palliative sedation and euthanasia; palliative sedation and artificial hydration; and risks and uncertainties in the clinician-patient/family relationship. We conclude that the three countries can learn from one another about the difficult issues involved in giving compassionate care to those who are suffering immediately before death. Future research should be directed at enabling dialogue between countries: this has already been shown to open the door to the development of improved palliative care and to enhance respect for the different values and histories in each.

Physicians' Opinions on Palliative Care and Euthanasia in The Netherlands

In recent decades significant developments in end-of-life care have taken place in The Netherlands. There has been more attention for palliative care and alongside the practice of euthanasia has been regulated. The aim of this paper is to describe the opinions of physicians with regard to the relationship between palliative care and euthanasia, and determinants of these opinions. Cross-sectional. Representative samples of physicians (n = 410), relatives of patients who died after euthanasia and physician-assisted suicide (EAS; n = 87), and members of the Euthanasia Review Committees (ERCs; n = 35). Structured interviews with physicians and relatives of patients, and a written questionnaire for the members of the ERCs. Approximately half of the physicians disagreed and one third agreed with statements describing the quality of palliative care in The Netherlands as suboptimal and describing the expertise of physicians with regard to palliative care as insufficient. Almost two thirds of the physicians disagreed with the suggestion that adequate treatment of pain and terminal care make euthanasia redundant. Having a religious belief, being a nursing home physician or a clinical specialist, never having performed euthanasia, and not wanting to perform euthanasia were related to the belief that adequate treatment of pain and terminal care could make euthanasia redundant. The study results indicate that most physicians in The Netherlands are not convinced that palliative care can always alleviate all suffering at the end of life and believe that euthanasia could be appropriate in some cases.

Quality of consultation and the project ‘Support and Consultation on Euthanasia in the Netherlands’ (SCEN)

Objective Consultation of another physician is one of the requirements for prudent practice. The project ‘Support and Consultation on Euthanasia in the Netherlands’ (SCEN) is aimed at professionalizing consultation. The objective of this study is to assess whether the quality of consultation was improved through SCEN. Method In four districts all general practitioners (GPs) received a pre-test questionnaire approximately six weeks before the start of the project in the period ( n = 1224, response 71%). In the period from April 2000 to December 2002, all GPs in districts in which SCEN had been implemented received a written post-test questionnaire one and a half years after the start of the project. This post-test questionnaire was returned by 60% of the GPs ( n = 3614). Results In SCEN consultations the attending physicians has no specific relation to the attending physician in 85% of consultations, while this is the case for 31% of other consultations. While before the start of SCEN in 71% of consultations six or seven of the seven criteria for good consultation were met, in SCEN consultations 83% of cases six or seven of these requirements were met. GPS who had consulted a SCEN physician generally were more positive about different aspects than those who consulted another consultant, such as considering the consultant to be able to make an independent judgement (totally agree 74% versus 59%). Conclusion Although the quality of consultation appears to be high for both SCEN physicians and other consultants, the SCEN project further contributed to the quality of consultation. Since GPs attach importance to judgement of SCEN physician and have the intention to use it in future, and the quality of consultation stays high over time, this project is expected to maintain its value.