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Dutch euthanasia… an easy death? For
Philip Esterhuizen RN, BA(Cur) MScN, PhD
Philosophy of care
‘Care delivery’ can only be referred to if the needs of
the individual patient are taken into account when
providing care and professional treatment.
Euthanasia is a deliberate life-ending activity undertaken
by someone other than the person involved at their
‘Deliberate action of ending life’
‘by a person, other that the person involved’
‘at their request’
What euthanasia is not…
 Non-commencement or stopping of treatment because
the patient refuses treatment.
 Non-commencement or stopping of treatment because
(further) medical treatment would be futile.
 Alleviation of suffering by administering prescribed pain
 Ending life without request.
Physician assisted dying in the Netherlands
Per year:
140.000 deaths
30.000 discussions about PAD
9.000 explicit requests
3800 die with physician assistance
» 3520 euthanasia (2,5% of all deaths)
» 280 assisted suicide (0,2% of all deaths)
» 3000 diagnoses of cancer
Cohort study on physician assisted dying in Utrecht
 198 patients with terminal cancer
(life expectancy < 3 months)
 140 agreed and could complete questionnaire
 Median age: 60 years
 59% discussed euthanasia (age: no difference)
 21% requested euthanasia (age: no difference)
 14% died with physician assistance (age: no difference)
Predictors for requesting physician assisted dying
Univariate (p<0,1)
 Pain
 Insomnia
 Depressed mood
 Religion
 Pain (odds ratio 1,37)
 Religion (odds ratio 0,21)
Depression and physician assisted dying
 Patients with depressed mood: 23%,
44% requested euthanasia
 Patients without depressed mood: 77%,
15% requested euthanasia
 Patients with request:
50% with depressed mood (HADS score> 20 points)
8% major depression (DSM IV)
Grief in family and friends of patients dying
Mean score (95% CI)
Natural death
Inventory of traumatic grief (ITG)
39* (38-41)
45 (43-47)
Impact of event scale (IES)
(posttraumatic stress reaction)
13* (11-15)
18 (16-19)
Symptom check list (SCL-90)
(psychiatric symptomatology)
116 (111-120)
121 (118-125)
* significant
Euthanasia and assisted suicide…
 Is punishable by Dutch Law
 An exception is…
A doctor,
Provides euthanasia on request of the patient,
Adheres to the guidelines and demands of care,
Reports to the coroner in accordance to the Law.
Guidelines and demands (1)
 The doctor must be convinced that the patient’s
request is enduring, voluntary and well-considered.
 The doctor must be convinced that the patient’s
suffering is hopeless and unbearable.
 The doctor must have informed the patient about
their situation and the prognosis.
Guidelines and demands (2)
 The doctor and patient have reached the conclusion
that there is no other reasonable solution for the
 The doctor has consulted at least one other
independent doctor who has seen the patient and
provided a written report regarding adherence to the
 The doctor has carried out the euthanasia or assisted
suicide with care.
Advance directives
 Sixteen en older,
 An advance directive written prior to the patient being
unable to communicate,
 Has same status as verbal request.
 Advance directives have no specific template and are
not bound to a limited time frame.
 A patient 16 and older, who is able to reasonably
access their situation, can request euthanasia if the
parents or guardian have been involved in the
 A patient between 12 -16, who is able to reasonably
access their situation, can request euthanasia if the
parents or guardian have consented.
Procedure (1)
 Well documented written report is essential and the
prescribed forms must be filled out.
 Report must be made to the coroner.
 Coroner presents report to regional commission for
examination – regional commission consists of an odd
number of representatives including a lawyer, a doctor
and an expert in ethics.
Procedure (2)
 Commission can request further information from the
doctor or any of the team involved in the activity.
 The doctor is provided with the commission’s judgement
within six weeks of submitting the report and can be, if
necessary, extended by another six weeks.
 If necessary, or requested, the commission will provide
the doctor with further explanation on the findings.
Procedure (3)
 If the commission finds that the doctor has not adhered
to the guidelines and demands, a report is filed with the
Attorney General and the Regional Inspector of Health.
The doctor is informed of this.
 The Public Prosecutor can, based on the report, call for
an investigation and commence with criminal
 All parties are legally obliged to provide any information
requested to further the investigation.
Procedure (4)
 The Regional Inspector of Health can put the case to the
Regional Disciplinary Tribunal.
 The Regional Disciplinary Tribunal examines whether
any acts or omissions have contravened the acceptable
standard of care demanded of the health care
professional by the Individual Health Care Professions
In euthanasia…
The patient has the right to request, but no obligation
to receive.
Medical staff have an obligation to listen, advise and
refer on moral grounds, but
the right to refuse,
Approach to schooling on moral decision-making
Principle-based ethics
 The value of life
 Goodness/no harm
 Justice
 Truth telling
 Autonomy
 Beneficence
Care-based ethics
 Moral attention
 Sympathetic
 Relationship awareness
 Accommodation
 Response
Evaluation of schooling
• Participant satisfaction
• Questionnaire
• Semi-structured interviews
Results from the questionnaires
• Assertiveness
• Current and adequate knowledge
• Discussion techniques
• Morally challenging situations
o Organizational
o Multi-disciplinary interaction
o Direct patient care
Results from the semi-structured interviews
Positive influence within the nursing team
Increased knowledge of jurisprudence
Improved communication
Increased knowledge and application of ethics of
caring / principle-based ethics
The hospital should do the patient no
Contact information
Philip Esterhuizen
[email protected]